To begin, we'll be learning the ASGE World Cup finalists and final award recognition. This will be hosted by Gerard Eisenberg, Chief Medical Quality Officer at UH Digestive Health Institute in Cleveland, and a member of the Division of Gastroenterology at Cleveland Medical Center and Case Western Reserve University, where he is a master clinician. Gerard, welcome, and we look forward to the program. Thanks, Brett, and congratulations on a terrific DDW program. It has really been a pleasure and honor to see all of the participants in this program. It's been an extraordinary year. I want to thank everyone who is joining this morning. This is a wonderful event. Most of you have seen the video plenary program where the best of the best videos were shown, and now we have the results of your voting for the Friendly World Cup competition. I really want to thank everyone for submitting their videos this year. I hope that you are in the process of developing new videos to submit for DDW 2022 in San Diego, and I look forward to everyone's submissions. So get your video cameras out, get your video editing skills up to date, and make those submissions. I really encourage you to do that. So we're going to announce the three winners this year of the bronze, silver, and gold trophies. And so first up, the winner of the bronze is actually David Diehl and Adam Kichler from the U.S., and this is entitled Wide-field Endoscopic Mucosal Resection of a Giant Laterally Spreading Rectal Tumor with Multiband Ligation Technique. You will be very surprised. Wide-field endoscopic mucosal resection of a giant laterally spreading rectal tumor with multiband ligation EMR technique. Author disclosures are as listed. We present a case of a 51-year-old healthy woman who was found to have a large laterally spreading tumor of the rectum on her initial age-appropriate screening colonoscopy. The patient was referred to our center for consideration of surgical versus endoscopic resection of the lesion. Advanced tissue resection techniques such as endoscopic mucosal resection and endoscopic submucosal dissection have been established as therapeutic options for the management of advanced mucosal neoplasia of the colon. Ligation EMR is a well-established technique that is achieved through the creation of a pseudopolyp using a band ligator followed by electrocautery snare resection. While not performed routinely for the management of colonic lesions, ligation EMR is an integral component to the multimodal approach to the management of Barrett's esophagus. Ligation EMR can be safely performed in the rectum below the peritoneal reflection and may provide a potential role in the management of large rectal lesions that are amenable to endoscopic resection. The decision was made to start with a flexible sigmoidoscopy for repeat evaluation of the lesion and to proceed with resection depending on endoscopic findings. At the time of the endoscopy, a nearly circumferential Paris 2a and laterally spreading granular tumor was found in the rectum extending from the dentate line approximately to the middle transverse rectal fold. As you will see in the following video, this lesion was resected in a piecemeal fashion utilizing a serial ligation EMR technique. In order to achieve a complete resection, a total of 54 band ligations with mucosal resection were required to be performed. Upon insertion of the endoscope, a flat granular type laterally spreading polyp could be seen extending from the anal verge up to at least five centimeters into the rectum. The lesion was circumferential distally and about 80 percent circumferential more proximally. Using an argon cautery probe, the borders of the large flat polyp were marked to facilitate identification of the extent of the lesion prior to resection. A mixture of saline with a few drops of methylene blue were injected under the flat polyp prior to commencing ligation-assisted EMR. The polyp was found to lift well in all areas. Utilizing a standard multiband EMR device, a suitable area of the polyp was identified and suctioned into the cap. Then, a 7-fringe snare was placed below the band and the snare tightened. Forced coagulation was used to resect the resulting pseudopolyp. In a stepwise fashion, further band-assisted resections were done. An area of polyp immediately adjacent to a previous resection is identified and the ligation and snare procedure repeated. The edge of the cap is positioned so that the remaining polyp is suctioned into the cap before band deployment. The resection margins are quite clean and no bleeding was encountered at all during the procedure. As can be seen, previous marking of the borders of the lesion was helpful to maintain orientation during the multi-step procedure. Towards the end of the procedure, some residual polyp was seen near the dentate lie. Even in this distal and difficult location, the band and snare technique worked well. Finally, the edges of the resection were cauterized with snare-tip soft coagulation. Here is the appearance after a 54-band, wide-field EMR resection. The appearance is very similar to what would be seen after an endoscopic submucosal dissection. The pathology specimen was reviewed and was consistent with adenomatous mucosa with tubular, villus, and serrated features. The patient did not experience any post-procedural complication and was without any complaint when she returned for a surveillance endoscopy three months later. At the time of endoscopic follow-up, mild narrowing of the rectum by a scar is seen, along with a small area of residual polyp. Powered endoscopic debridement was done to address the small amount of polyp which remained just above the anal verge. This resulted in complete removal of the residual polyp. As demonstrated in this video, ligation EMR can be safely performed for successful resection of large, laterally spreading granular tumors of the rectum that abut the dentate line. This is a novel application of an established technique that is commonly performed in general gastroenterology practice. While we are not suggesting that this approach is superior to traditional resection techniques, we pose that ligation EMR may serve as a potential alternative when faced with a technically challenging or lengthy ESD or traditional piecemeal snare EMR. Additionally, ligation EMR for rectal lesions may be adopted in situations where end block resection is not required and when the patient or referring provider may not have access to tertiary referral centers capable of complex EMR or endoscopic submucosal dissection. So as you can see, that was a awesome video demonstrating a technique that was applied in a different manner. So congratulations, Adam and David, for this video and for winning the bronze based on the popular vote. I'm going to move on to the silver award winner. This is from Russia and Alexander Prick is the primary author. It's a case of endoscopic diagnosis and treatment of an extended circular LST lesion of the rectum with subsequent development of the cicatrial stricture and its further balloon dilation. You will actually see something which is quite unique and certainly I can see why those of you who voted in this way, this is a terrific video. Please enjoy. The case of endoscopic resection for large circumferential rectal LST with the subsequent development of tight stricture and its treatment. These are our disclosures. Sixty-two years old male was referred to our center with complaints of constipation over the last three months. Clonoscopy revealed lateral spreading tumor, granulomic subtype, that occupied 100% of the rectum of the anal verge up to 10-11 cm. Here you can see the examination of the LST lesion. Lesion was observed in the NBI mode and assessed by the NICE classification as type 2. We consider the ESD procedure the best way for LST treatment, because the risk of recurrence is low and quality of life remains good. Margins of the lesion were determined before performing the ESD procedure. Primary incision of the mucous was performed by the dual knife from the side of the anal verge with the preliminary lifting of the incision site. We decided to use tunneling technique to create two tunnels and then connect them. There were no signs of somucosal fibrosis, but there were a lot of relatively large vessels of the somucosal layer, so in order to prevent bleeding, they were coagulated with the usage of coagulant. Fortunately we managed to avoid any major bleeding. During the procedure, we use different types of knives in order to make dissection safer, easier and faster. Here you can see some causal tunnel, and there you can see the final step when we connected two tunnels. The remaining mucosal tissue was cut by the core grasping. After complete removal of the lesion, the assessment of the wound surface was performed. There were no signs of perforation or bleeding. Here you can see the whole lesion after its removal. The size of the lesion was 11 cm. Duration of the operation was 11 hours. Histopathological assessment revealed set cells rated adenoma of rectum with low-grade dysplasia. Post-operative course was uneventful. Butasonide 2mg form had been administered from day 3 after ESD once daily for one month to prevent the development of rectal structure. Colonoscopy one month after the ESD showed a circular healing wound surface with signs of mild inflammation. The lumen is freely passable by a 14 mm endoscope. Butasonide treatment was stopped after predetermined taper. Two months after ESD, patient complained of difficulties with defecation. Endoscopic examination revealed no signs of recurrence, but a tight structure 7 cm from any leverage with a length of about 2.5 cm. Not passable with a standard 12.8 mm endoscope. We decided to start treatment with balloon dilation of the structure. Within 10 months, 5 outpatient sessions of lumen dilation with a balloon from 12 to 18 mm in diameter with 7 atmosphere were performed to achieve a stable response for treatment. Sometimes, after balloon dilation, we observe small superficial ruptures in the stricture zone. After the treatment, the lumen was freely passable by a 14 mm endoscope, and there were no difficulties with edification. Patients who underwent total circumferential ESD of rectal tumor had a high risk of strict transformation, despite local steroid treatment. Multiple sessions of dilation might be necessary to elevate the stenosis and to achieve a steady response. Wow, so I don't know how long that took. It certainly seems like a procedure that probably took more than an hour, but also the fact that they were able to take the specimen and place it on a small cylindrical bottle of some sorts, that must have taken some doing as well. Anyway, congratulations to Alexander and his colleagues from Russia. I'm pleased to announce the gold trophy. It actually goes to Brazil. They somehow were able to perform this procedure using a technique that has been shown before, but in a somewhat more unique manner. Congratulations to Brazil for winning. I wish I had my World Cup jersey for Brazil to wear, but maybe somebody from Brazil can donate it to me. This is the video entitled Treatment of dejunal duodenal anastomosis dehiscence with endoscopic vacuum therapy. Treatment of dejunal duodenal anastomosis dehiscence with endoscopic vacuum therapy. Primary author, Marcos Eduardo Leira dos Santos. Co-authors, Igor Proença, Fernando Pontineto, Gabriel Sousa, Antônio Madruga Neto, Facundo Galetti, Epifanio Monte Jr., Diogo de Moura, Igor Braga, Eduardo de Moura. These are our disclosures. Clinical case. We report a case of an 81-year-old woman who presented considerable weight loss in the last six months, associated with change in the consistency of stools. Computer tomography of the abdomen and pelvis showed thickening in the descending column, measuring 2.5 centimeters. There was also a synchronous lesion in the rectum, which was located 5 centimeters from the inner border. Colonoscopy was performed, followed by endoscopic submucosal dissection of the lesion in the rectum. In the descending column, an ulcerated lesion with an infiltrated aspect was addressed, with an stenosing component. In the rectum, we identified a vegetating lesion, which was better evaluated using narrowband imaging, NBI optical chromoscopy technology. We opted for the endoscopic submucosal dissection to remove the lesion in the rectum. The procedure was carried out without complications. This is the final aspect of the resection bed at the end of the procedure. Histological analysis identified venous adenoma with low-grade dysplasia in the rectum, and colon biopsies showed invasive adenocarcinoma. After two weeks, partial left colectomy was performed, with colorectal and osteomosis. During the procedure, there was a duodenal adenovirus in the rectum. During the procedure, there was a duodenal advertent injury, which was repaired with duodenoraphy. Two days after surgery, patient presented clinical worsening and bio-outlet through the abdominal drain. Exploratory laparotomy was performed. It was found the resence of duodenoraphy. Thus, enterotomy was performed with duodenal dejunal and osteomosis. The patient remained in the critical condition, with severe acute pancreatitis. Twelve days after surgery, there was clinical worsening and bio was found in depth of the drain. Thus, a new computer tomography of the abdomen and pelvis was performed, and the CT showed a collection of the left flank and free liquid inside abdominal cavity, but no leak after oral contrast intake. The main diagnostic hypothesis was another resence of the duodenal dejunal and osteomosis, being opted for conservative treatment. But it was unsatisfactory after two weeks. The new tomography images on the 27th of the operative day showed free fluid and pneumoperitoneum. The first endoscopy was performed 28 days after the first approach. We could confirm the resence of the duodenal dejunal and osteomosis with transmural defect, and fluoroscopy showed contrast leakage due to transmural defect. We opted for vacuum endoscopic therapy. We used nesogastric tube with gauze at the distal tip and covered it with artificially fenestrated sterile plastic. Then, we fixed it with nylon wire. The nesogastric tube tip was placed in an intracavitary position and connected to a negative pressure system. The second endoscopy was performed after seven days. Significant decrease in the size of the transmural defect was evidenced, also confirmed by fluoroscopy. We opted for interluminal EVT placement. The third endoscopy was performed two weeks after EVT. Endoscopy did not identify a transmural defect, only shallow ulcer. Fluoroscopy confirmed no contrast overflow. A new CT was performed 42 days after surgery. There were no free liquid in the cavity or pneumoperitoneum. 14 days after EVT, patient presented a better clinical condition, being discharged 22 days after the beginning of endoscopy therapy. Clinical Implications EVT is a relatively recent and promising technique in the treatment of GI fistulas and dehiscence. It has been reported good results in case series and cohort studies. EVT should also be remembered after failure of other treatments. Conclusion EVT takes relatively short time to close anastomosis dehiscence. In our case, EVT was the choice after failure of both surgical correction and conservative treatment. Congratulations again to Brazil, to Dr. Santos and his colleagues. This has been a wonderful session. Congratulations again to all the winners. As Ed Dellert has shared with you, we know that you're interested in seeing the other World Cup competitors. And you can actually view these videos in the resource room. For those of you that want to see the video plenary videos in case you just didn't get a chance to see those during DDW, as well as the best of the best video award winners and the honorable mention videos, you can go on to ASGE's GI LEAP website. The World Cup videos will also be available there. Thank you again for joining us. Brett, do you have any other comments that you want to make before we leave? No, I just really enjoyed those three videos. And as the years pass, all of these techniques are seeming more and more accessible to those of us who aren't mucosal-based endoscopists on a daily basis. So really wonderful demonstrations. Thank you. And congratulations to the award winners.

Gerard Eisenberg

ASGE World Cup competition

bronze trophy

silver trophy

gold trophy

gastroenterology