Good afternoon, and welcome back to this afternoon's session. We're beginning with a program entitled Best of ASGE Research from DDW 2021. This is a formulation of what's been identified in our topic fora as outstanding and useful to all of you. This session will be facilitated by Vanessa Chamney, Professor of Medicine and Director of Endoscopic Ultrasonography at the University of Virginia. Vanessa was the primary speaker for the ASGE component of Best of DDW at our recent virtual convention, and will bring some of that along with several of her colleagues to bear over the next 90 minutes. So welcome, Vanessa, and thank you for what's to come. Thank you so much for that kind introduction, Brett. Just as a little bit more background for the audience, for DDW 2021, there were a total of 798 abstracts that were submitted, and 186 of these were selected for oral presentations. I really had the true honor of selecting five subject matter experts who were tasked, it was a tough task, to choose and present what they felt to be the very best abstracts from the ASGE based on one of five designated topics. Now during the presentations, please feel free to ask questions by typing in that Q&A box, which we will do our very best, I promise you, by the end of this session to address most of those questions, or as many as we can. So without delay, the first presenter is Dr. Vani Konda, who is Clinical Director in the Center for Esophageal Diseases at Baylor University Medical Center. She's extraordinarily well published in this area, and will present the best esophageal abstracts. Thank you so much, Vani. Thank you, Vanessa, and thank you to the ASGE. It is my pleasure to share some of the exciting work shared at DEW this year, focusing on the esophagus. And I will only get to share some of the abstracts, but please visit the online platform to learn more. These are my disclosures. And starting with swallowing disorders from the top, I want to share two studies about Zenker's diverticulum. The first study is presented by Al Ghamdi et al., and they perform an international multicenter cohort study examining the different outcomes for two approaches for the entry mucosotomy between a hypopharyngeal mucosotomy and a septal mucosotomy in terms of technical success, clinical success, adverse outcomes, and recurrence. And they had 53 patients with the hypopharyngeal approach and 121 patients with the septal approach. They report while there is no difference between technical success, clinical success, adverse outcomes, or recurrence, they found that the total procedure time was significantly decreased in the septal mucosotomy approach and shared that it was technically easier, which led to the shorter procedure duration time. Another multicenter study compared Z-PALM technique with septotomy with 49 patients with the septotomy approach to address the Zenker's diverticulum and 52 patients for a Z-PALM approach. And while there were no significant differences in terms of the technical success and the clinical success and length of time for the procedure, they found that there was an increase in adverse events in the septotomy group compared to the Z-PALM group. Moving down the esophagus to achalasia, a systematic review and meta-analysis looked at differences in outcomes between two approaches, one implementing a short myotomy and the other standard approach with a standard myotomy length. And review of seven studies was conducted with a meta-analysis. And in summary, they found that a short myotomy was as effective as a standard myotomy in terms of clinical success, and reflux symptoms were similar between the two approaches. But objectively, a short myotomy had a lower risk of pathologic reflux and a lower risk of reflux esophagitis noted on endoscopy. And speaking of reflux, in this multicenter prospective cohort registry study, Mimi Canto et al. demonstrated their experience on the safety and efficacy of TIF with the second generation version with enhanced technology and a specific technique with 30 fasteners aiming for a greater than 2-centimeter fundoplication and aiming for greater than 270 degrees in terms of the RAP. They report that these patients had a significant reduction of reflux symptoms with a reduction of GERD HQRL from 24 to 6 and a reduction from the RSI from 13 to 4. Objectively, they also had a decrease in the mean acid exposure time from 9 to 3, as well as 80 percent normalization of acid exposure time after TIF. Clinically, there was a reduction of PPI use with patients specifically reporting that their satisfaction with regards to PPI increased from 11 percent to 94 percent after TIF. And moving on to Barrett's esophagus, the diagnosis of dysplasia has always been a challenge among pathologists, and this multicenter retrospective study evaluated the assessment of cases with indefinite for dysplasia. They had four pathologists evaluate dysplasia, these cases with indefinite for dysplasia, and then they had a washout period of eight weeks where they reassessed the cases, but this time with P53 immunohistochemistry staining. And they found that the addition of P53 allowed for a significant reduction of those cases that were still labeled as indefinite for dysplasia, as well as letting the other cases get either downgraded to nondysplastic Barrett's or upstaged to low-grade dysplasia or high-grade dysplasia. The addition of P53 also enabled a substantial agreement between pathologists in the diagnosis of dysplasia. Another more novel approach for the diagnosis of dysplasia was this study, which aimed to leverage artificial intelligence techniques and utilize a deep learning model to diagnose dysplasia in histologic slides with Barrett's esophagus. So a computer-aided algorithm tested over 500 patients, and the per-patient sensitivity and specificity of low-grade was 99% and 95% respectively, and that of high-grade dysplasia was 100% and 95% respectively. The Dutch group provided their experience of patients with confirmed low-grade in their centralized care system in the Netherlands, where all patients with confirmed low-grade are referred to a Barrett's expert center within three months. Of the 222 patients who had low-grade dysplasia without visible lesions diagnosed on the initial endoscopy, they reported that after the repeat endoscopy at the expert center, 80% were found to have visible lesions, and 24% of those patients were upstaged to high-grade dysplasia or cancer. This underscored the importance of improved detection during a Barrett's examination and consideration of a referral to a center with Barrett's expertise. Indeed, detection of visible lesions can be challenging, especially because early neoplasia may be subtle in Barrett's esophagus. And again, we see the use of artificial intelligence in this study, which explored artificial intelligence to be used on video sequence images, and it used a deep convolutional neural network to highlight areas of concern as seen on this green box. On patients with dysplasia, they had 20 cases with dysplasia and 20 cases without dysplasia. The AI-based algorithm demonstrated that it had a 95% per lesion sensitivity among the dysplastic lesions, and the per patient negative predictive value was 100%. Another potential approach for detection in Barrett's esophagus is molecular imaging. This phase 2 study with 38 patients used a topical-based marker, which labeled bevacizumab, and used near-infrared fluorescence to detect lesions, which lit up on imaging, as you can see on the picture on the right. The near-infrared molecular imaging detected all lesions seen by white light, as well as an additional 14 lesions not seen previously by white light endoscopy. Detection after treatment is also a challenging issue, and this prospective multicenter study registry by Eluri et al. demonstrated the use of Watts, the abrasive brush combined with a computer network-aided detection for dysplasia, and they demonstrated a 1.9-fold increase in the rate of identifying any recurrence after endotherapy. And another study by the Dutch group reported their experience on patients who did not respond well to radiofrequency ablation, and they described two groups, one, a group with poor healing after the radiofrequency ablation noted with visible ulceration or mucosal swelling, and the second group was that with poor squamous regeneration, so the mucosa came back barrett's instead of squamous. They found that among those patients with poor healing, the patients could still be treated with more time and acid suppression, and half of those cases will likely respond to treatment, whereas those patients who have poor squamous regeneration are more likely to fail radiofrequency ablation therapy. They suggest that among those patients that demonstrate poor healing, potentially more time treatments and acid suppression can lead to successful therapy, but for those patients who come back as barretts, they may not achieve endoscopic eradication, and a careful consideration should be made whether or not you should just continue rigorous surveillance for those patients who don't still have dysplasia versus alternative measures for those patients who continue to have dysplasia. A study by Agarwal et al. performed a multicenter propensity score matched cohort study comparing two ablative methods, radiofrequency ablation and cryo-balloon ablation. They had 85 patients in each group, and they found that both modalities led to comparable results with no significant difference in eradication, durability, or complication rates. And the Dutch group reported their experience on specifically ESD cases. They had 130 cases of ESD in their national cohort study of patients who were treated for their barretts neoplasia, and these cases often had suspicion for submucosal invasion or they had large bulky lesions. The combined rate for N-block and R0 resection was 87% for T1a lesions and 49% for T1b lesions. Among the patients with R1 resection, they routinely performed a follow-up endoscopy, and at that follow-up endoscopy post-ESD, they found that in 71% of the patients, there was no neoplasia detected. Of those that underwent endoscopic surveillance, they did not find any further evidence of neoplasia. And among the few patients that went on to still have surgery, they did not detect any residual neoplasia in the surgical specimen. And among the patients at that endoscopy who had neoplasia after the post-ESD endoscopy, they went on to get surgery or systemic therapy. This suggests that after ESD, even in an R1 resection, a repeat endoscopic assessment would be valuable to guide further management. And that is the end of my esophageal section, and I'll be happy to take questions later.

Best of ASGE Research from DDW 2021

Zenker's diverticulum

achalasia

reflux

Barrett's esophagus