We appreciate your participation in tonight's webinar. My name is Ed Dillard. I'm the Chief Publications and Learning Officer here at ASU. Me and I will be one of the facilitators throughout tonight's presentation. Our program tonight is entitled The Role of Interventional Endoscopy in the Management of IEDs. Please note that this presentation is being recorded and will be posted on GILeaf ASU's online learning resource package. You will have ongoing access to the recording in GILeaf as part of your registration. I also want to acknowledge tonight's registrants for programming support from Olympus for the remainder of the 2021 ASU University Night Lights program. Thank you to them. Before we get started, please note a number of features in tonight's platform to our aware of the many resources available to you during and after tonight's program. Currently, you are located in the auditorium as you enter the lobby. You should note the meeting information is past time, and then a few reference that might be of interest to you. There are also other resources located in various sections that you can access. In the resource room, you will find a number of options, including Video GIE, Master Videos, History of Endoscopy section, a Gaming section, if you so desire, as well as access to a number of ASGE guidelines that are in other resources in GIE. In the networking lounge, you will find access links to completing evaluation surveys for tonight's webinar. We would appreciate you completing this, and it only takes a couple minutes or less to complete. Finally, I would also guide participants tonight to the virtual exhibit hall. This is where there are a number of resources provided to you, including an ASGE booth. If you have any questions, just swipe your virtual badge and a representative will get in touch with you by email. Thank you for noting all of these features available to you during the webinar and any time even following this program. Again, this is just a URL link to where we will be posting the recording of tonight's webinar on GIE, and you will also note that there are a number of other webinars in GIE that you can have access to. Tonight's objectives, before we introduce our faculty, are three, to learn the use of advanced endoscopy techniques and management of structures related to IBD, and to learn techniques to perform endoscopic episiotomy, sinusotomy, and abscess drainage of patients with IBD. And finally, learn how to perform endoscopic resuscitation of patients with IBD. It is now my great pleasure to introduce our faculty tonight. Let me first start with Dr. Kofar, if you would introduce yourself and your affiliation. Yes, thank you, Ed. So my name is Goswami Koshwar. I'm the associate division chief of Department of GI and Hepatology at Allegheny Health Network. My research interests and endoscopic interests include endoscopic interventions in IBD patients, including work around structures and fistulas. So I have a dual practice, clinic practices, IBD and endoscopy. I do all advanced endoscopy procedures. I'm very thankful to ASG for this opportunity. I hope all of you guys take advantage of this session and please feel free to ask us questions as well. Thank you so much. Thank you and welcome. Looking forward to your presentation. Dr. Hsieh, can you introduce yourself? Yes, hello. Thank you again for ASG and then Dr. Kocher and to put all the things together. And I am a professor of medicine and surgical sciences at the Columbia University. And my special interest is in the intervention of IBD and endoscopic therapy for inflammatory biotidies as well as ileopathy disorder. And now my practice mainly at the New York Presbyterian Hospital and at Columbia University. Thank you for having me. Excellent. Thank you, Dr. Hsieh. And finally, Dr. Dragunov. Hey guys, glad to be here. Peter Dragunov at the University of Florida. My main interest is advanced therapeutic endoscopy of all kinds, including endoscopy, endoscopic resection and third space endoscopy. Thank you. Excellent, Peter. Thank you very much to all three of you. And just before we kick off our presentation with Dr. Dragunov, I think, just a reminder that in the Q&A box that's in your footer of your Zoom, you can enter your questions and we would encourage you to enter your questions there. Presentations after each lecture tonight, we will pause and have some questions and answers and then we'll move on to the next lecture until the very end. And then we'll do a final Q&A before we conclude tonight's webinar. So without further ado, Dr. Dragunov, I think we will hear from you first and looking forward to your presentation tonight. Thank you very much, Ed. Let me take control of the screen. I'm gonna point your attention to a very recent AGA clinical practice update on endoscopic surveillance and management of colorectal dysplasia, inflammatory bowel disease. And this is the reference that came just a couple of months ago in a gastroenterology. I will be referring to this document, but I will gonna take it beyond it. I'll give you some additional information, although this is a great place to base your current practice. I wanna also point out that this is not a guideline. The AGA puts this clinical practice updates, which do not raise to the level of being a guideline, but they try to give the latest and the greatest that may not necessarily be supported to the extent and scrutiny that the typical guideline is made, but it's meant to be more nimble and provide more up-to-date information. And this is the clinical practice update that I was referring to. But before I go there, I wanna point a few very important things. The first of all, screening colonoscopy should start eight to 10 years after diagnosis of colitis, both alternative colitis and Crohn's disease-related colitis. A question that comes routinely on the US GI boards is that if you have a patient with PSC, they should undergo a screening colonoscopy at the time of the diagnosis of PSC. Even if they had a recent colonoscopy, let's say a year ago, patient comes up with PSC, you should rescope them and reevaluate for the presence of colorectal cancer or dysplastic lesions. This is a very important point frequently tested on the boards. It goes without saying that screening colonoscopy should be performed when patient is in remission, otherwise you'll see a lot of inflammation and you can overlook significant dysplastic lesions. And in 2021, the use of high definition endoscope is highly recommended. If in your unit you still have a standard definition endoscope, please use the high depth for the patient with IBD. There are still a few controversies. The first one is, is dichromoendoscopy necessary when using high definition white light endoscope? We know that with a standard definition, chromoendoscopy is routinely recommended, but in most cases, at least in the United States, we routinely use high depth endoscope. Do we still need to use a chromoendoscopy with methyl in blue or indigo carmine? The second controversy is, can you use virtual chromoendoscopy such as NBI or BLI instead of dichromo? And finally, is random biopsy still necessary? Let me address those one at a time. Is dichromoendoscopy necessary? This has been a topic of intense research including a number of randomized controlled studies and meta-analysis and systematic reviews in the recent years. So all of those have been published in the last three to four years. And the bottom line is that the majority of the studies support the notion that high definition white light endoscopy is as good as high definition white light endoscopy plus chromoendoscopy. What does the AGA guideline says? They say that dichromoendoscopy should be considered in all patients in standard definition endoscope, of course, that is definitely the case, or if there is a history of displacement. And this is very important. Even if you're using a high definition endoscope, but the patient has prior history of displasure, you should consider chromoendoscopy. But then there is elaboration on this point, which says that virtual chromoendoscopy with NBI, narrowband imaging or blue light imaging, BLI, it's a suitable alternative to Dice-Bray. So in my own clinical practice, I do not routinely perform dye pan chromoendoscopy, but I routinely use a virtual chromoendoscopy on demand in this case. The next area of controversies is random biopsy necessary. And I'm just presenting you with a randomized controlled study results of random versus targeted biopsy. Not 10 chromoendoscopy was done, but selective use of chromo was applied if visual was detected. And the bottom line is that the same yield to detect displacement was seen in both arms. But, surprise, surprise, random biopsy chromoendoscopy took much longer, 41 versus 26 minutes, and random biopsy chromoendoscopy required more biopsies, 35 versus three biopsies. But are random biopsies dead? And the answer is not quite yet. A more recent study in 100 patients, they did high-depth white light endoscopy plus chromo in all patients. And they found 140 neoplastic sites in 94 of those patients. 80% of the neoplastic sites were detected by targeted biopsy, meaning that they saw a visual abnormality and then took a biopsy of that visual abnormality. But 20% were detected only on random biopsy. And in 12 patients, the displacement was detected only on random biopsy. So if you look at the yield of neoplasia on random biopsy, per biopsy is exceedingly low, 0.2%. If you look for chromoendoscopy, it's still low at 1.2%. But if you look at the displacement detected, random biopsy yield was 12.8%. So one can make a case that random biopsy may still be recommended in selected patients. So who are those patients? We know that random biopsy are time-consuming, expensive, and have a low yield. But they should be considered for platelet closure in areas previously affected by colitis when white light endoscopy is used without dye or virtual chromoendoscopy. But we use either chromo or virtual chromo in all patients, so we should be using that even when we are doing high-depth endoscopy. So my approach is to do random biopsies in selected patients, long-standing IBD or extensive inflammatory pseudopolyposis, where you can easily overlook displasia because you see a bunch of protruding region. I think that is a reasonable practical approach, but in most cases, I do not do random biopsies. So now, if you detect displasia, the question becomes, what do you do with it? And the bottom line is that endoscopic removal of dysplastic regions protects against development of cancer. It was not too long ago when if you detect any dysplasia in IBD, that meant a colectomy. That is no longer the case, and in most cases, we can provide alternative surgical colectomy by providing endoscopic therapy for dysplasia. But that was always in the details. Some regions are suitable for endoscopic resection, some are not. But before I go into that discussion, I want to very briefly remind you the recommended way of describing regions in IBD. Basically, we should be using the Paris classification process descriptor. The Paris classification divides the regions in polyploid, which can be either potentiolated or sessile, and non-polyploid, also referring to literature as flat. The non-polyploid could be 2A, and this is two examples of 2A. Those are slightly elevated. They could be flat. Those are rarely seen, but we do encounter them every so often. Or depressed, or I should say slightly depressed. Those are the two Cs. So after you describe a region that you have detected on colonoscopy, by the Paris classification, then you should add a descriptor. Is alteration present or not? Or is the border easy to identify? And you should provide this information even if it is negative. In other words, you should say this is a Paris 2A region measuring whatever size with no alteration and discrete borders. It's important for us to be talking the same language in order to facilitate patient care and to be on the same page. So where do we stand on the use of endoscopy for therapy of dysplastic lesions? And the clinical practice update states that all clearly delineated dysplastic lesions without stigma of invasive cancer or significant sudden loss of fibrosis should be considered for endocopic resection. The important disclaimer, and this is very important in my opinion, is if the resectability of the lesion is in question. In other words, if you're not sure, please report to specialized endoscopies or IBD center. Do not directly send the patient to a surgeon, but give that patient a chance to be evaluated in a center that has a high level expertise. And I'm gonna elaborate why that is a good clinical practice. So what do I do in my own approach to patients with the IBD with dysplastic lesions? Simply, if they have polyps that are in segments uninvolved with colitis, I'll resect them. Keep in mind that patients with ulcerative colitis or chronic colitis can get standard tissue polyps. Like everybody else, as we get older. If the lesion is polyploid, sessile, or pedunculated, most definitely those should be given primary consideration for endoscopic therapy rather than surgery. The area that we have more recently expanded into, by more recently, I mean over the last 10 years or so, are the non-polyploid or flat lesions, there is 2A, 2B, or 2C. And those are fair gain for endoscopic resection if they have well-defined border, if they're relatively small, and that is a general statement what relatively small means, that is in the eye of the decoder, and if there is no submucosal fibrosis. But more recently, we have gone even further. With the advent of ESD, now we can tackle non-polyploid lesions that are large, and also that contain submucosal fibrosis, which unfortunately is frequently seen in dysplastic lesions in IBD because of the underlying inflammation. Keep in mind that in standard lesions outside of the IBD, if there is submucosal fibrosis, that is one of the indications of de-submucosal invasion of any present cancer. That is not the case in inflammatory bowel disease, and frequently lesions will not lift or will have the non-lifting sign simply because of denying fibrosis rather than the presence of invasive cancer. So consider referral to center with ESD expertise in those lesions as well. What is the role of ESD in IBD? There is some information. All of that information is basically for case series. We don't have any randomized controlled studies for sure, but the results are quite positive. As you can see, those are two studies from Japan. The last one is a study from the United States that included our center. We find that most of those lesions are resectable with a very respectable unblocked resection rate, well into the 90%, and curative resection in the majority of the cases with minimal rate of complications. Importantly though, the patient is always at risk and metachronous lesions can be seen. So ESD now has expanded into therapy regions in IBD that were previously not manageable by EMR because of non-lifting sign and simply because of fibrosis present underneath the lesion. So summarizing, managing dysplasia in IBD, one is to consider endoscopic resection as the primary modality for all polyploid lesions. And as a reminder, both of the sessile lesions or the dunculated lesions. Endoscopic resection should also be considered for flat nonpolar point lesions with well-defined borders. And those can be resected by EMR. But now, as long as the lesion has a well-defined border, it can be resected also with ESD, even if subnipotent fibrosis is present, and even if the lesion is large. On the other hand, one should consider surgery for flat lesions with indistinct borders, multi-focal dysplasia, and extensive inflammatory pseudopolyposis, although granted, this is definitely a last resort. I wanna end up with actually my probably most important recommendation to please strongly consider referral to center with high-end expertise in IBD in patients in which we detect dysplasia, either by seeing a discrete lesion or on random biases. Why? Because those patients typically need the medical management part. They have been already through a few biologics. They may be ready for their third or fourth. So you need the medical expertise. They definitely may need advanced endoscopic resection technique expertise. And if they need surgery, it's a great idea that surgery to be done by colorectal surgeons with specific focus on IBD. My final slide in conclusion is that to use the Paris classification, to which we have the descriptor of alteration or border disability when doing your report on patients with IBD undergoing surveillance colonoscopy. Careful examination with high definition white light endoscopies and targeted biopsy remains the point of display the detection with the emphasis being in careful examination. This is not the case where you should stick to the six minutes or seven minutes withdrawal time. You should take longer and you look very careful. The role of dying virtual program or endoscopy and random biopsy still remains controversial but it appears that virtual colonoscopy is adequate substitute for dichroma endoscopy when used in conjunction with high depth white light endoscopies. But random biopsy, although not needed in most cases are necessary in some cases. Patients with longstanding colitis will be the main category. Consider endoscopic resection for all polyploid regions and for flat regions with well-defined borders. And finally, again, I want to emphasize please consider referral to the patient to a center with high-end expertise in IBD management in both medical, endoscopic and surgical areas. Thank you. Thank you, Dr. Dragunov. We've got a couple of questions here that I'll pose for you before we move to Dr. Shin's presentation. The first one that we have kind of follows in on the flat region. So do you think that almost all of the flat lesions need EFD as almost have underlying fibrosis? Hope that makes sense, what I just said. That's a great question. And I will say that a lot of them do. And if you decide to tackle your health in your endoscopy unit, it's okay to inject saline and to see whether they lift and do EMR. But please don't inject any viscous solution underneath those lesions because even if they have some fibrosis, you will make that issue worse by injecting or eyes or any other viscous solution. I would love to hear what other two experts have to say about this issue. Bo, what do you think? What's the percentage of fibrotic lesions with dysplasia in IBD? So actually the majority of all depends, I think this duration of the disease. If the duration, if the disease is longer and the chronic inflamed, it's a high risk. And also my personal experience, by extensive long duration with the use of the biological agent, you increase risk of fibrosis. If the patient is just only exposed to the like the 5-SA steroid and all the immunomodulator, the fibrosis actually is mild, but all the biological agent, even like in VRC and more and more people with ulcerative colitis with the structure, it's all related, but the exposure to the long-term exposure to the biological agent, especially those with the quick healing, like the anti-TNF alpha. Interesting. Do you think that the biologic is basically a stronger marker for more severe disease rather than the biologic causing the fibrosis? So this in the both, I think that if you have a severe disease, use a biologic agent. Biologic agent promoted tissue healing, but fibrosis is the natural process for tissue healing. But unfortunately, you know what, give the endoscopist a hard time when you have the fibrosis. So that's why I fully agree, not everybody should try the ESD-EMR for the dysplasia in IBD. You need to refer to the expert center, like your place and then Simran's place. Simran, I'm sorry. Don't try it at home. I'm sorry. Don't try it at home. Yes, yes, no, I agree with what Dr. Shen has said and Peter, what you said, excellent presentation. I think ESD remains still very challenging in IBD patients. We do always, as the question was asked, we do almost always encounter some fibrosis. And I think that's where the trick and the challenge lies. And I think if I was reading correctly in the Q&A box, the other question part was, is there any special tip or technique that we use for ESD in these patients? Obviously, Peter is more experienced than I am, but I have done a few of these. And in my experience, I do use the tapered tip. I do use the hook knife more than the other knives because then I can hook the fibrotic tissue and cut it. I do schedule these cases with ample time and not a cramped up time, because even a 15 millimeter lesion can sometimes take close to two hours, which can be painful. But I think that there is no as such any special trick, I would say be patient, don't be afraid to switch knives. There has been situations when I have switched from nano knife to hook knife to an SB knife. Like in one case, I've used multiple knives. It just depends on the degree of the fibrosis and how good of a lift you get. I'm still an old school guy. I don't use the newer solutions for the lift. I still mix my own methylene blue with Hespan. And I use that with some normal saline. I've also used techniques like the hybrid injection with the Irby company. Again, no conflict of interest, but these are just some tools. I want people to be aware that they are there. And that's why in a specialized center where we do high volume of these cases, we are in tune of switching between these items. And going back to Peter's point that we should only try to tackle this if we are confident that we can reach the end of the procedure. Otherwise, it makes our life very, very difficult once it has been half worked on and then sent to us. We completely, and just for those people in the audience that do ESD, this will be probably the last frontier of ESD. If you're early in your ESD career, don't start with IBD or even. It will be very difficult to do. Ed, do we have time for another question verbally or we should switch back to the next talk? So we can take one more question and we'll move on to Dr. Shin. Okay, go ahead. I don't know. I think that last question on the bleeding with these cases was the last one that I had here. So I think we're okay. There wasn't a question, but I think Dr. Shin answered this online, which was patients with PSC, IBD would need yearly EGD colonoscopy, correct? And I think he's already responded to that. I actually have a question for Peter. How about a patient with a dysplasia in IBD, but the PSC had a portal hypertension? Oh, now we're getting up there. Thank you very much for making it easy. So first of all, I want people to realize that patients with PSC and IBD are at higher risk for colorectal cancer. So they need to be surveyed at more intensive intervals. Secondly, although portal colopathy can be seen, it's tend to be less severe than portal gastropathy or esophageal or gastric varices. So on the limited patients that I have had, I don't find that bleeding tends to be that big of a problem and also consider that colonic ESD tends to bleed less than gastric or esophageal ESD. So I don't find the major difference there. To me, the biggest obstacle is fibrosis, which makes any type of infection that much more difficult. If you have advanced PSC and the patient is considered for transplant, certainly consideration may be given to colectomy at that time, if it is positive colitis, because then there'll be only immunosuppressants and it becomes quite difficult to monitor. But I have not found portal pressure influence to be a major player in this action. Thank you. Thank you, Dr. Dragunov. That was an excellent presentation as always. We love the questions and the responses on the discussion with that. I think let's move on to Dr. Shin's presentation. And if you're ready, Dr. Shin. Yes, I'm ready. Thank you, Peter. So today's topic is endoscopic fistulotomy, sinusotomy, and abscess drainage. That basically we take away some of the business from all colorectal surgeons as an endoscopist. So this is my disclosure. So as we know that the natural history of the chronic disease dictate that a majority of the patients will eventually develop the kind of the complications. Major complications are the structure, fistula, and abscess. And even that patient out of surgery, you still can develop an asthmatic structure or disease-associated structure and an asthmatic leak. So if we talk about the endoscopic therapy or the medical therapy, the window period is the first three to five years. But however, when you treat the patient with aggressive medicine, medical therapy, the one of the drawback is rapid tissue healing then cause fibrosis and cause the complication too. So that's why, so when the mechanical complication happen typically after three to five years and then structure, fistula, abscess happen, the mechanical complication should be treated a mechanical way. Traditionally, we treat it with a surgery, but then we will notice that this endoscopy play the growing role in the management of the IBD complication and the IBD surgery complications. So in our field, there is the doctrine said, no inflammation, no structure. No structure, no fistula. No fistula, no abscess. So the chronic inflammation, the cause of biofibrosis, transmural, and then you have a pre-stenotic dilatation and then you have a sidetrack of the fistula, the fistula leading to the abscess. Now this is actually the surgical specimen given by my mentor, Dr. Fazio. This x-ray showed the iliopsoas structure with the psoas muscle abscess related to the fistula. Now x-ray. Now the current indication for endoscopic therapy or IBD or intervention IBD, I summarize into the four major category. First one is a structure. The Dr. Kocher will talk after me. And then fistula and abscess, surgical leak and colitis and associated neoplasia as outlined excellently by Dr. Jaganoff. Now, the first talk is on the fistula and abscess. So we use a tool. We use a knife, it's a simple tool. There's a needle knife and IT knife. And each has a pro and cons. With the same setting, needle knife is more powerful than IT knife. IT knife is safer and more expensive because it has a ceramic tips. Now what's the tool for the device, for the devices? For the device, for the devices. Then here's we said, we use a lot of the clips. Sometimes we use a 20, 25 clips as a spacer for the treat the fistula or sinuses. So the other things, sometimes we use overscope the clips. Sometimes we use other tools as shown here, guide wire and the stand. Now here is the slide showed this, what is the acute anastomotic leak and the treatment. So the leak, if you have the leak or abscess, then this abscess here, your rule, it is a drained abscess. Either use a needle, surgery or through the intervention IBD. And you can drain the abscess actually internally. Especially abscess associated with an asthmatic leak. And then after the totally drained abscess, you can put the clip on top of that. So this is the endoscopic fistulotomy. There's a chronic abscess leading to the fistula. The fistula, this is the behind, you know, pouch. Bowel to bowel fistula, you can use a knife to basically to cut this off and you can lay open the fistula track and then lay down for the clip there. Now here is another bowel to bowel fistula. And in the patient with the ileopulchral surgery, you can see the guide wire. You can see the fistula from here to here. And then you can use a knife to cut through it. This is a slide that we borrowed from the ASG, GIE magazine. It showed this like that, if we have a tight structure at the ileocecal valve, the leading to the ileum and the cecal fistula. This is the best scenario. Actually, you treated that structure, we call it stricturotomy. In the meantime, you lay open the fistula track, we call it fistulotomy. Then you put a clip in between the two track and then lay things open. Basically, you can completely cure that fistula and the structure. Now that Dr. Kocha and I did a study, that time we have how many patients, 29 patients, for various kind of the IBD-associated fistula. Then, so result is, let's show it here. So the majority of the patients, 96% of the patient fistula get cured. The complication rate is very, very low. And then I think that not all the fistula can be treated by endoscopy. We only selected the patient with a short fistula and a superficial fistula, especially after biosurgery. Now, sometimes we do the endoscopic drainage of the abscess. Since we are already in the endoscopy room, the patient had the perianal abscess. As long as not across the sphincter or outside sphincter, you basically can use a knife to treat it. And you can even put a guide wire through it. And with the guide wire, you can introduce acetone. These are called endoscopic incision and drainage, and acetone placement through the guide wire. Now, here's a summarize of the endoscopic treatment of the fistula and the sinuses and abscesses. So most of the patient need abdominal imaging, cross-sectional imaging with the CT-MRI. If the patient is stricture, you treat the stricture accordingly with the endoscopic balloon dilatation or endoscopic struturotomy. If the fistula is anastomotic and distal bowel and short and shallow and presacral, you may try the endoscopic fistulotomy, sinusotomy, and even cleft. And if the patient has the disease-related fistula, if the patient had a fistula to the other organ, such as the bladder or vagina, those patients need a surgical correction. People with the abscess, if it is around the anastomosis or around the perianal area, you can do the endoscopic incision and the drainage. Even you can put it a pigtail stent and or acetone. How about a surgical leak? Surgical leak, this is a list of all the common surgery for chronic disease. You can have the ileocolonic resection with the ileocolonic anastomotic leak and all at the leak, we call it transvasal staple line from that area. And also the patient with the stricture plastic had the leak too. And the patient had the leak is here, leak is here. And then patient had the stoma side also had the leak. Leak, the source of the leak, typically at the facial side of the stoma, intercutaneous type. So if the patient had the ileopouch and a common place of the place of a leak is tip of the J as shown in here. And then it's another common place where the leak, it is number one place called a presacral area. So here is a technique we use. If the patient has acute leak with abscess and sepsis, you try to incision and drain, you can use a sponge, you can use a pigtail. And if it has a defect, it's acute leak, you can use a sclerotoscope clip or over the scope of the clips. For chronic leak, you have the two form, either fistula or sinus. As again, we showed that if the fistula happen, you can do the fistulotomy, CTOM placement or clip, especially the clip at the anastomosis, the intercutaneous fistula. And if the people have the presacral sinus, you do sinusotomy. So the principle of the endoscopic therapy for acute leak, the drainage first, clip second. So here to show the abscess around anastomosis, there is area, the pelvic abscess, very hard to do the transcutaneously. So the IR give a little bit hard time for us. Then we use way to endoscopic, use a guide wire to detect the abscess track. And over that jag wire, you can put a pigtail stand there. And then this lead to internal drainage. After the abscess totally drained, later on you can put it over the scope of the clip to click that leak. Yep, take a little bit of time to break the cap stem. So now this is the Europe and some other institutions in the United States use the endosponge for the acute leak and it has a mixed result and I, when I was at a Cleveland clinic and are now currently at the Columbia University, some of the surgeons occasionally use it and I found the result is pretty good. And then if you have an acute anastomotic leak, it's fresh, if the leak is small you can try the endoclips, if the leak is a big you can do the over the scope clip like here. Here is like the patient had a rectal vaginal fistula with an acute leak, it's fresh, as long as it's a fresh, this is the leak from the ultragenic trauma, you can do a guide-wide based over the scope clip. Here is a rectal vaginal fistula, we place the clips and then you do the repeated gastrography enema, the fistula with cured. Now this the tip of the J leak is very common in people with the ileal pouch, not very common, actually happened to about one percent to two percent. So we over the years we have a collection of the 12 cases and you use the over the scope the clip, the long-term success rate is a short-term success rate of 100 percent, long-term success rate about 67 percent, in other words two-thirds of the patient can avoid surgery. Now the principle endoscopic therapy for chronic surgical leak, chronic surgical leak, the fistula, this is showed as a here is a bowel and here is the skin. Now fistula you treat, try to close the internal opening either with endoclips or over the scope the clip. Then you try to use the open the skin up with a knife, so this is the way how to treat the fistula. For the sinus, the doctrine you do it is you try to make the things, the opening wider to drain the things inside, drain the sinus inside. So this is a slide that showed how do we do the sinusotomy. You can see the pre-sacral space, there's a sinus there, sinus basically the chronic chronic abscess cavity. This is a J pouch, you basically cut that wall between the sinus and the J pouch body and lay things open and put a clip there. This, by this maneuvering you can do, you can convert the sinus into the bigger diverticulum of the pouch. So here the highlight, how do we do it? Here's the sinus, here's the bowel lumen, you have a needle knife ready and then of course sometimes the cutting has a little bit of bleeding, you put the clip on both sides and then make the sinus open and the drain into the lumen of your bowel. This is the sinus shown in here, the 11 o'clock, 11 o'clock is the posterior wall of the bowel and you can use a knife, either use an IT knife or needle knife to let things open and then drain it. And this is the three months afterwards, you can see the area already epithelialized, this is the base of this chronic abscess cavity or cavity of the sinus. So there is an option also to do the surgical therapy, basically totally redo pouch, rebuild, take three stages and very costly and very invasive and the bottom line actually numerically endoscopic therapy offer the better option and the better outcome than surgical pouch redo. And then importantly, the complication rate is 43% in the surgical arm and then 7.3% in the endoscopic arm. So therefore, in our recent guideline, we recommended the patient if have the presacral sinus, the first line therapy is endoscopic sinusotomy. Now chronic anastomotic leak from the sinus to the fistula. So this is a sometimes the leak too long and then you may need a drained abscess outside, put the mushroom catheter there in the endoscopy room and you do the needle knife therapy from inside for the sinusotomy that basically will cure the patient. So normally the people have the rectal vaginal fistula and pouch vaginal fistula because of the chronic, very hard to treat. But however, if sometimes the fistula track in the rectal side or pouch side is tiny, you may try over the scope of the clip like here. In summary for fistula therapy, the fistulotomy, if feasible, is the first choice. The next one is drainage and the third one is the clip, the opening, the internal opening of the fistula. For the surgical leak, if the acute leak, the first choice would be adequate drainage. Close the defect even if it isn't temporary. Chronic leak with the fistula, close closure of the internal opening and open up the external opening. And if chronic leak with the sinuses, we do the sinusotomy. I have a few slides to tell you, the audience, about the future of the interventional IBD you want to share with us. So the future in interventional IBD, we have faced a little bit of challenge and the opportunity with the standardization, training, accreditation, and the reimbursement. So our group, Dr. Koucher includes the interventional IBD group, global interventional IBD group. We publish the position statement. We also publish the guideline in the lens of gastroenterology. The first document is the endoscopic management of the Crohn's disease structure. And the second document, endoscopic evaluation of the surgery, altered bowel in the people with IBD. Now, how about training and accreditation? And I'm glad our colleague, the Czech Republican, Dr. Lucas and his colleagues created this, the PIC model for the structure. It's very, very helpful. And in the future, hopefully people can get trained there. Now, how about the reimbursement? Because the cost can be issues. So we have an article, the poster to be presented in this coming ACG about a cost-effective analysis. Use a balloon with the surgical therapy. And then later on, we do the cost-effective analysis with different endoscopy technique and different surgical technique. And then that will convince the insurance to have some reimbursement, solve some reimbursement issues for those innovative endoscopic procedure. Thank you very much. I'm happy to entertain any questions. Thank you, Dr. Chen. That was an excellent overview and presentation. I haven't received any questions, but I do want to ask Dr. Dragunov or Dr. Kothari, if you had any key points or questions you might want to pose, Dr. Chen. Yes, I think excellent presentation, Dr. Chen. As always, nothing new, beautiful slides, beautiful diagrams. I think one thing when I have given a similar talks or lectures, people have always asked me, do I have a knife preference? I know you mentioned nano knife versus needle knife. Have you encountered any specific complications, increase in bleeding or anything like with a particular knife, or you just go by the shape of the fistula, length of the fistula, and how thick the tissue that you want to cut? I think it's a, so it all depends. I believe the needle knife has a high risk for immediate bleeding and IT knife for delayed bleeding because you created a more, the larger ulcer area. So if the fistula is very thick or the bowel wall is very thick, I tend to use needle knife. I started with a needle knife, then I use changes to IT knife, now I go back to needle knife. But the needle knife, very important to ask your anesthesiologist, do not over-survey the patient. If the people had a big breathing, the bowel is up and then belly is up, down, and the bowel is moving, and then needle knife is not a great choice. I want to totally agree with Bo about his approach because conceptually the needle knife wire is much thinner. The result, it cuts much better, but it does not coagulate very well. Correct. While you get more bleeding. Yeah. So I totally concur with that. On the other hand, the IT knife, the shaft is thicker. Sometimes it's hard to cut with. Yes, correct. You get less bleeding. In some cases, as Bo suggested, you have to use both knives for the same case. Correct. As much as expense that is, if that's what you need to do, go for it. I like that approach, Bo. I'm with you on that. Thank you. Perfect. Dr. Chen, if I may ask one more question to you while you have, because we touched on the topic of training and accreditation, and hopefully we'll have more hands-on sessions and with your conference coming up, have more educational material for people. But for people who are starting new, for the audience who's starting new, would it be safe to tell them that the first fistulas they should tackle is probably the pouch body-to-body fistula, so they can cut towards the lumen and then make their way up to the icy anastomosis and other areas? So I think if you really want to train the people to do the fistulatomy, start with the perineal fistula. Perineal fistula. Perineal fistula, because the perineal, the key thing is I don't touch a wrinkle. The border of the wrinkle is the external sphincter. As a gastroenterologist, you never mess up the external sphincter or internal sphincter. Leave this to your correct surgeon. But however, any fistula outside the area, right, it's just cut. Since it's already there, you train abscess. Today, actually, I have a patient. I need to go see that patient. They already had abscess admitted yesterday, and our surgeon just scheduled it so far. Then until the six o'clock, they get the abscess trained. Now, if they happen to be in me with the colonoscopy, I happen to see the abscess with the drain, the pus come out, why not? I have a needle there. I just numb the skin with a lidocaine, clean the skin with a betadine, just knife through it. You can palpate the fistula track. You can cut the things with a knife, and then you actually can do the partial fistulotomy. Perfect. Peter, one question for you. Have you ever done U.S.-guided abscess drainage in the rectum perineal area in IBD patients? Absolutely. It's very similar to pancreatic pseudocystic or Waldorf-Konkursus technique. You use the linear endoscope, and as long as you have a well-defined rim around the fluid collection, it's actually quite safe to do. Now, with the addition of lumen opposing stance and hot lumen opposing stance, it makes the procedure that much easier. Okay. Actually, Simran, go back to your question. So recently, I did a video visit with one of the patients from San Antonio. The patient had the tip of the J leak and has abscess outside of the J pouch. And what the local surgeon did as an endoscopy is try to find that leak, cannot find the tip of the J leak. So they use the EUS, make the hole to the stent towards the drain abscess, the puncture the healthy bowel. I'm not sure this is the right way to do it or not, because I have another patient in the hospital. Same thing with the pelvic abscess, cannot be drained, and local did the drainage through the vagina. They put the drainage catheter through the vagina. Now it's a vaginal fistula. So that's why if you try to put the stent there, try to find an asthmosis or natural leak. Do not puncture the new hole in the bowel. I 110% agree with that. Definitely going through the vagina, that is, I think it's absurd. Yes. Create a much bigger problem than you thought. Yeah. And the plus of the IBD patient, right? IBD patient that even like the de novo hole, sometimes very hard to close it. That is, you know, so yeah. Perfect. All right. So great discussion. I think if you are ready, Dr. Kochar, we'll move on to your present, yours and the final presentation for tonight's webinar. Perfect. All right. Thank you so much, Ed. It's always a challenge to go after your mentor, you know, who prepares his slides so well. But good evening, everyone. Thank you for joining us. You know, intervention IBD is a new and upcoming area that both, you know, me, Dr. Shane and with the help of Peter, we are very excited to bring it to you. Hopefully it grows more and it helps you all guys in your practice. So today I'll be talking on emerging options of managing strictures in IBD. So the objective for my talk is what are the newer options like endoscopic stricture at me? And what is the role of enteral stenting for IBD? Something we get asked very often. So strictures in IBD, they're basically luminal narrowing that may lead to partial or complete obstruction. They are result of long-standing inflammation, terminal ileum and ileoclonic junction of predominant locations. In this diagram, you'll see the three most common types of strictures that we encounter. A web-like stricture. The second image is of a spindle-shaped stricture. And the last is an ulcerated fibrotic stricture, which we often encounter in our practices. We don't have a very good incidence rate on this. Recently, there was a meta-analysis that looked at that, but we believe the prevalence is somewhere around 5 to 24%. There is no effective medical treatment for strictures. If there is some inflammatory component, you can give anti-TNF or steroids, but still they are not as effective. Surgery still remains the gold standard of treating strictures. So if I was to, you know, divide stricture management into three options, medical, endoscopic surgery. Under endoscopic, the mainstay of stricture management for years has been endoscopic balloon dilatation. Endoscopic strictureotomy and stent placement are the newer options. And these will be focus of our talk today. So starting with endoscopic strictureotomy, as Dr. Shen alluded to his talk before, the global intervention IBD group that we started recently published the first guidelines. And most of my talk will be based on the recommendations and the consensus from this paper, if you guys would like to read. So strictureotomy basically use an electro-incision knife to widen the lumen of the ball. It can be performed in radial, horizontal, or circumferential fashion. We call this technique a strictureotomy, once in which we only use the stenotic lumen of the GI tract to widen the incision alone. And we term it endoscopic strictureoplasty when we use the, through the scope clips to basically apply at the cut edges. I do not have any conflict of interest with any companies, but these are the equipment that most commonly I use. And people ask me this question. So I use the setting of endocard Q313. I use the nano knife and hook knife predominantly more than the other types of knives. So let's start with a brief case here. A 32-year-old female who is status post ileocolonic resection is now presenting to you for management of anastomotic stricture. She's nine months postpartum. The stricture is at the neo-TI anastomosis, one centimeter in length, and she is currently being maintained on biweekly Adalimumab for her Crohn's disease. She recently was hospitalized secondary to bowel obstruction. She did undergo a balloon dilatation with one of my colleagues to 15 millimeters about four weeks ago, minimal relief in her symptoms. She did have a CT and triography in hospital that shows a mild stricture at TI with mild pre-stenotic dilatation and then mucosal enhancement in distal TI. This is the endoscopic picture that my colleague took before the balloon dilatation. So which of the following options would you recommend? Do you recommend repeating the balloon dilatation and consider dilating to 18? Or you should dilate with injecting intralesional steroids? Should you perform strictureotomy? Should you do surgical resection? Or should you switch medications from anti-TNF? So in this case, we went ahead and did So in this case, we went ahead and did a strictureotomy. I have a video of this case. I'm going to show you. So basically we go in and we are in a semi-retroflex position. It's an end-to-side anastomosis. As you can see, even with passing my scope, there was some blood from the trauma. So we use an IT nano knife. My goal usually is to make a circumferential incision, but sometimes given the scope position in a post-op anatomy, that's not possible. So we tried dissecting it. Now, I do like to get to cut the scar tissue till the level of submucosa. Obviously, you should never cut it to the level of muscle or beyond, because then you'll have the perforation. But there always comes a point, at one point when the submucosa scar tissue is cut, just like in this case, you get a give-away feeling from the stricture. The tension that is built up, it kind of gives away. So we continue to cut. And then after a while, I tried to pass my adult colonoscope, and that is freely able to pass to the TI. And in the new TI, there was not much inflammation. It was just this one stricture that was the cause of problem. So we were able to advance the scope. On your way back, you can cut a little bit more. You have more scope control. In the end, I was able to place clips all around. The clips serve two purposes. You'll see as I share the data more, post-procedure bleeding remains a concern. So clips help with that, and also clips prevent from the edges that were freshly cut to come back together and form a new stricture. So one-year follow-up, the image you see is like this. The colonoscope goes through it as if no issues, and the patient is still doing well. So what's the data on stricture autoimmune IBD? As you will see, the majority of the data comes from Cleveland Clinic, from Dr. Shen's group. Dr. Lan and Dr. Shell published almost all the papers in this regard. But if you see, overall, more than 200 patients included, almost all the locations in the GI tract that you can imagine, more than 90% success rate, almost 100% success rate. I didn't have success in one patient. My denominator was low. So that's why we have 92% success rate. But overall, very high technical success rate of completing the procedure. Adverse events are listed here. I know the percentages can seem high, but you have to look at the denominator. So one out of five patients had a complication. And when we specifically talk about complications, when I'm doing a balloon dilatation, my main concern is perforation. So if you look at just a perforation column of all the studies, we had total four perforations that were reported. If you look at the bleeding, bleeding is the main problem that we have. So that drives our adverse event rate up. So significant bleeding post-stricture atomy is almost seen in about six to 9% of the patients. And it is irrespective of the stricture location or the length of the stricture. So that is something we're still trying to figure out as to how to get better at. But the good thing is the rate of perforations is low. And which makes clinical sense. Because when you are doing a balloon dilatation, once the balloon is dilated to a particular size, the radial force is transmitted. You can't take it back. With stricture atomy, you have a very precise control of the knife as to where you are cutting and how much you are cutting. So that's why I think the risk of perforation is low. So again, from Dr. Shen's group, they looked at stricture atomy versus ileocolonic resection. The follow-up time was longer with ileocolonic resection, because the patients was more in this group. Symptomatic improvement was, the P-value was not significant, but was almost 60% in the stricture atomy group and 83% in the surgical resection group. However, disease-associated hospitalization was also higher in the surgical group than the stricture atomy group. This, to me, is the most important takeaway from this paper, that was stricture-related secondary surgery was similar in both the groups. Although the P-value was not statistically significant, but that was secondary to the small number in the stricture atomy group, but almost similar number of patients requiring the secondary surgery. How does stricture atomy does compared to balloon dilatation? So the technical success, immediate technical success was much higher in the stricture atomy group than balloon dilatation. Symptomatic improvement was also higher in stricture atomy patients, and need for additional therapy was lower in stricture atomy patients compared to balloon. The main question of perforation in this study, they reported no perforation, while there was a risk of, there was about 2.4% rate of perforation in the balloon dilatation group. And perforations in IBD patients are very different from perforation in a normal patient. A perforation in an inflamed IBD patient, I think almost always you will not have a chance to endoscopically close them. So they almost always require a surgery. And the perforations in IBD patients happen irrespective of the balloon size you choose. So it's not like higher the balloon size, the higher the perforation. So sometimes people might think that they might just dilate to 12 millimeter, that is less risk of perforation. It's not like that. Perforation depends on how much the stricture can handle and can even happen dilatation with balloon of 10 millimeter, 12 millimeter, and so on. So what has been my experience at AHN? We have so far performed 81 cases. The locations are almost everywhere from upper GI tract to anal strictures to primary colonic strictures. Technical success rate has been 100%. Clinical success has been 98.7%. Bleeding, again, remains significant, about 6%. There was one perforation up in the duodenal region, which was managed conservatively. The longest follow-up period has been 33 months so far. So what are the advantages of stricture atomy? I think you preserve the bowel length. Obviously, you are more controlled, as I explained, compared to balloon dilatation. Dr. Shen's paper showed that you can have similar surgery-free survival. We feel that need for repeat procedure is less, and I think it's very good for anal strictures. I'm going to share a case here. A patient with PSC underwent total colectomy. Jay Pouch has a very fibrotic stricture. She has been self-dilating herself once a week for last God knows how many years. Even an EGD scope doesn't pass through. So we saw her in the clinic. We brought her in, and we decided to do a stricture atomy in this case. I very carefully avoid the posterior vaginal wall or the interior rectal wall, because that's a very thin wall. You want to avoid current on that side. So we go to the posterior rectal wall here, and we are trying to cut the stricture in a semi-circumferential fashion, you know, cut the scar tissue out. Now, remember, this is a person who's been self-dilating herself once a week to at least evacuate her bowels, get better with the symptoms, and her symptoms are mainly obstructive in nature. We were able to get rid of the scar tissue, and then the scope passes easily. The Jay Pouch was definitely very inflamed. It had not had endoscopic surveillance before, so we completed our surveillance. I have been following this patient since for at least last one and a half, two years. We have not had a need to do further stricture atomy, and she has stopped self-dilating herself. So a very common question, because balloon dilatation still remains the gold standard, can we combine them? The answer is absolutely yes, we can combine them, and I'm going to share one video here very quickly. This is an anastomotic stricture. This is your classic, you know, the spindle-shaped stricture that comes and goes. I'm completely retroflexed. We tried to cut the stricture. The small intestine was prolapsing. I was not getting a good look through at the stricture, so I decided to cut the mucosa first. We get a good view of the stricture, and I start cutting again. My endoscopic position being retroflexed was not great, and I was not able to have a good look, so that's when I decided to use the balloon dilatation. I had already done the cutting part, so it was still okay. And I like to usually dilate the balloon and then adjust my dials in a way that I can see through the dilatation. And once I do that, then I like to see the whitening of the mucosa because that tells me the adequate stretch has happened. I almost don't use fluoro in almost all my cases unless indicated, so this technique helps me to do that. So, as you can see here, whitening of the mucosa, you know the stretch is adequate. And this is what it looked after, the balloon dilatation. And I was able to get across to the small intestine, and the patient did have inflammation in the small intestine, and we were able to change her medications accordingly. On my way back, I did a little bit more cutting circumferentially, if you saw, and then I obviously applied the clips as I do. And then the patient did perfectly fine after the procedure. In this next case, the next video I have for you, okay, here we go. So, this is a primary TI structure, patient never had a surgery before, sorry, primary IC valve structure, very tight structure, won't let the scope go through. So, I decided to use a balloon first to dilate. We were able to dilate to a size, I believe, of 15. And just remember, to get your adult colonoscope through, you at least have to dilate the structure to 15. To get your EGD scope through, you have to dilate to 11 or 12 millimeters. So, after this, we were able to get across to small intestine, because as you can see, looked very healthy here. She had one structure, very close to IC valve, but then we came back to our IC valve structure, and we decided to cut the structure open. As you can see, it's a pretty generous cutting, we go all the way to the level of the muscle, the structure was cut. And as I mentioned before, once you cut to a level, the structure just gives away. And you get that feeling, and the scope passage became so easy after that, with no issues. This was her second structure, we also did endoscopic work on that. And then we just applied CLIPS to this. And then patient was discharged home after the procedure, she had no issues. It's been about eight or nine months since we did this, and the patient is doing clinically great. So, how about primary colon structures? Absolutely, yes, I don't have a video for this, but I have the images, and as Dr. Shen explained to you before, no structure, no fistula, no abscess. So, if you look here, this is the structure opening, this is ascending colon, and then there was a little fistula opening here around the side. So, we were able to do endoscopic structure atomy on this patient, we opened it up, the terminal ilium is towards this side, and this is the cecum here. And this is how the structure looked after the procedure, and the patient did very well with that. Billing is not rosy about structure atomy, there are definite drawbacks. It does require extensive training and expertise, knowledge of therapeutic endoscopy, knowledge of your devices, knowledge of how to manage complication all comes in handy. No billing code means that all these 90-minute procedures that you have to do, you have to get a buy-in from your division chief or your institute chair to let you do these for the sake of the patients, as these are time-consuming. Complications like bleeding, we're still trying to figure out what's the best way, but that still remains a concern, but it is better to have bleeding than to have a perforation, I believe. So, I think it's a give and take, and you have to have a very honest discussion with your patients before the procedure. So, how do I approach a patient with structure? I always get a pre-procedure, CTE, MRE, and that's the recommendation from our paper as well. If the size is less than three, I favor structure atomy. If it is between three and five, I favor balloon dilatation. If there is a lot of inflammation, I do try to tweak their medications, but if the patients have very severe pre-structural dilatation, or the length is longer than five centimeters, I think we should consider surgery, because in long-term, endoscopic therapy does not help these patients. Moving on to enteral stents in IBD. So, stents have always been an avenue of interest in IBD from early 1990s, but the results were not very encouraging. This is a table that summarizes the most recent and the largest case series, as I call them, you know, of the stents that people have used at various locations from ileocolonic and anastomosis mainly, and the stents usually have been self-expanding metal stents. The technical and clinical success rates are very high. The duration of stenting is all over the place for different studies. I'm going to focus on this study by Das et al., which was published last year in GIE. It gained a lot of attention. They included 21 patients that underwent stenting with them. The majority of strictures were anastomotic. There were only two TS strictures, and only endoscopically impassable strictures were included. However, if you read the details of the paper, the group decided to exclude the strictures that were considered inflammatory on the endoscopic inspection, and in their definition of inflammatory strictures include any stricture that had any degree of erythema, mucosal engulfment, disease vascular pattern, mucosal friability, erosions, spontaneous bleeding, or any frank ulcers. Unfortunately, that's the 99 percent of the patients that I see in my practice, so probably they won't fit the trial. So the technical success in this trial was up to 96 percent, and the average stricture length as defined by the endoscopist was about 3.3 percent. And all of the strictures were found to be dilated to the stent diameter after the study in interval. They report five adverse events, three stent migrations. All stent migrations necessarily are not adverse events. Only the proximal should be an adverse event. Distal migration can happen, especially when the stricture has dilated. And then two patients presented with severe abdominal pain that had to be hospitalized while the stent was in place. So what are the issues with SEMS and IBD? So the procedure, you know, has been associated with adverse events, such as bowel perforation, migration, facial affirmation, from the early data, 1990s. The most recent data is pretty good. Technical success is good, but sometimes we do see premature stent failure. We don't have dedicated IBD stents, at least in the U.S. we don't have that. And there is always a tissue reaction to foreign body in patients with Crohn's disease, be it a stent, be it a PEG tube. You know, patients with IBD don't like foreign bodies usually. Duration of stenting is a big problem. Some people keep the stent in for four weeks, some remove in two weeks. We still do not know what is the ideal duration of stenting. So because of that, and also we don't have long-term follow-up data on these patients as to how many patients underwent surgery at the end of one year, two year, three year period. But the future of, you know, self-expanding metal stents in IBD is very bright. These are some of the fully covered stents. Obviously, Axio stent is everyone aware of, you know, there are other stents that are coming out in markets with other companies, which are fully covered through the scope. You don't, you know, you can deploy in places where you normally might not be able to deploy the ones that go through those scopes. So I think the future is looking bright. This one video I want to share of using, and this is a non-FDA approved indication, I must specify to the people here, this is, again, you have to have a discussion with your patients. This patient had a very tight duodenal stricture, pinhole stricture in the duodenum first portion. And we decided to, you know, she was treated with balloon dilatation at least two or three times and the stricture was not going anywhere. And duodenum is one area that bleeds a lot of a stricture at me. So we decided to stent this. As you can see, we're using an XL canola under fluoroscopy. We pass a wire and then over the wire, we pass the axial stent. We deploy one phalange on the other side and the second phalange on the gastric side. And once the axial stent was deployed, even after the axial stent, there is always a risk of migration. So I basically used over the scope suturing system here to suture the stent in place. We always dilate the axials to the size, so this was dilated. And then here, as you can see, we use the over the scope stitch device and we were able to place the suture and keep the stent in place. And patient immediately felt relief of her symptoms. She did exceedingly well. I removed the axials, I believe, after four weeks after cutting the suture. The risk of migration is greatly reduced with the endoscopic suturing. So the future direction for endoscopic management structure, I think endoscopic structure at me at some point eventually might become primary modality. There is a concept of looking at drug eluting balloons as we do these. Drug eluting stents are also in the mix. I think use of 3D printing can be very helpful to delineate the structure, especially for those angulated structures and long structures. It can also give you an idea about the vascular supply, the blood supply, and that can help you plan your cases much better in future. Obviously, 3D printing is still expensive and not available at every center, so that's why I put in the future direction. So in conclusion, I think endoscopy is and will continue to be a major player in management of IBD. And management of IBD complications based on endoscopy should become mainstream. And I think as our technology is getting better, we need to optimize our training to keep getting better. And to optimize the training, these are some of the ways you can be involved. And I think the most important way is the special interest group that ASG has created for intervention in IBD. Dr. Shen led it for the last two years. I'm the chair of the group this year, along with Jason Schreier, who's my vice chair. We do these webinars every two, three months focusing just on intervention IBD, and we are very thankful to ASG for that. Personally, you can get in touch with me at other sources as well. With that, I would like to say thank you, and I'm, again, very excited for this session. And thanks to ASG for giving us this opportunity. I'm more than happy to take any questions, as you guys may have. Thank you, Dr. Bhochkar. That was an excellent presentation, as always. We do have a few questions here for you. I'll just go from the start at the top and work my way down. The first one was about the middle part of your presentation. And the question was posed about, would you treat a structure with endoscopic therapy when there is active inflammation, especially a post-operative? Yes, very good question from the audience. So the answer is yes and no. I would treat a structure if there is inflammation, definitely, if the patient is very symptomatic. I do not have a problem treating a structure, dilating it gently, even if there is some inflammation. Now, it also depends what's the degree of the inflammation. If it is deep, surpingenous ulcer and, you know, it's very severe inflammation, then you don't want to dilate those patients or do structurotomy. So if it's a fibrotic structure that has an ulcer to it, let's say there is a patient who underwent ileal resection. Now you do a follow-up exam in six months' time. Let's say the patient doesn't complain of any symptoms, but you find a moderate structure and there is an ulcer at the anastomosis. The most recent guidelines we published along with, you know, Dr. Shen is the main author and he can comment as well. We did discuss that it is okay to dilate or treat the structure with structurotomy in these cases for the long-term benefit. That little ulcer that you see at the anastomosis, don't be afraid of that. That ulcer can happen because of localized ischemia to that region because of the surgery. That necessarily doesn't always mean there is a lot of inflammation. So I think it, A, depends on patient symptom, B, the degree of inflammation. But yes, I have treated structures even with active inflammation. Very good. Thank you. The next follow-up question was, how do you differentiate endoscopically between an anastomotic structure, endosurgical versus inflammatory structures, and would you approach them differently in terms of endoscopic anesthesia? Yes, very good question. Actually, this brings us, and I think Dr. Shen will be also able to chime on this, to our second guideline paper that also is in Lancet Gastro Hepatology on how to do an endoscopy in a surgically altered bowel. So when you reach the site of anastomosis, if all you see is a fibrotic stenosis and there is no signs of inflammation, there is no friability of the tissue, no granularity, no ulceration, you can very safely say this is a post-anastomotic structure. Again, going back, you might see a tiny ulcer just at the anastomosis, but the mucosa beyond or before that should be normal. On the contrary, sometimes what happens is when patients have very severe structure, because of the fecal stasis, so the very proximal segment, 3 to 4 centimeter, because of fecal stasis will have some inflammation. That necessarily does not mean that patient's disease is active. That just means that the stool is not draining properly. It's staying there longer. So the pure inflammatory structures you will realize have a lot of arrhythmia, a lot of friability, a lot of granularity. You touch the area of the mucosa, they start to ooze, and usually they're in a segment. They're not localized to one centimeter. I at least have not seen a patient with active inflammation that is localized to one or two centimeters. They usually tend to involve a segment. So that is one way of differentiating. Dr. Shen, do you want to say anything else on this? Simran, you're right. First of all, a lot of the people mentioned about what is a truly structure. A truly structure should be like the pre-stenotic dilatation with a radiographic view. We have our group, the interventional IBE group, has a debate about this isolated, ulcerated structure or even the ulcer in the anastomosis. Should we call it a Crohn's disease? Should we call it just because of surgical ischemia? We even debate using a biological agent to do a diagnostic trial. So I think it's like Simran is right. If the isolated structure in the anastomosis, above that, if there are only like two or three centimeters of inflammation, my take on it is the fecal stasis associated. So keep this in mind because I think the audience is interested more and more in the scopic dilatation. There are some tools. I remember the first question about do you dilate or treat the inflammatory structure? In my endoscopy room, there's always one solution always available, which is 50% glucose. So when you dilate the inflammatory structure, typically it has some bleeding. It's an oozing type of bleeding, not pulsatile bleeding. Then you use a spray can to spray 50% of the sugar. So ideally, you can soak it through it. And then after one minute, all bleeding will stop. And then when you treat anastomotic structure, what is a good sign you have the result that is good? If you use a knife to cut, either a needle knife, IT knife, if you find a dislodged staple, that is your best money. So if you find a dislodged staple, remove them. And then further cut. Then the result, the outcome is better. So I hope that answers your question. Perfect. So Dr. Kotar, Dr. Chen, maybe you can help in this inquiry. Would steroid injection at the site for the structure after intervention help in decreasing the scar and inflammation, like what we do in esophageal structures? Would either one or both of you maybe respond to that? Absolutely, we can. If you notice, Ed, both of us started smiling at this question because I think both of us have been asked this question almost every time. And it's a very important question. And we did address this in our paper in the Lancet-GastroHEP. So we at the Global IBD Group, in a very short, nutshell, believe that injecting intralesional steroids in IBD patient is not helpful because the data is conflicting. Now, there is very good data for esophageal structures, for peptic ulcer disease structure. I myself, if I have a peptic ulcer structure, I do inject triamcylone. But in IBD patients, we looked at steroid injection. We looked at a couple of pilot studies, looked at injecting anti-TNF into the injection site. But as of now, the position statement, the guideline, the consensus from the Global IBD Group says there is no benefit of injecting steroids in these injections. Also, if you're considering doing therapy on IBD patients, be it structurotomy or balloon dilatation, we also discourage those patients to be on high-dose prednisone because the complication of bleeding on high-dose prednisone is high. So if my patient is on 40 or 20 milligram prednisone, I like to stop them or at least bring them down to 5 milligram before doing this therapy. So in short, we recommend do not inject intralesional steroids. Dr. Chen, any further comment on that? Or do you want me to move to our final and last question? Yes, I agree with Dr. Kocher. Initially, in our practice, many years ago, maybe 20 years ago, we inject a steroid, even inject anti-TNF alpha. We found it's not effective. It's also supported by the current literature. So that's why the consensus of the guideline, we do not recommend intralesional injection before, during, or after the endoscopic therapy, either with a balloon or needle-knife therapy. Thank you very much. Our final question this evening is, how would either one of you be sure during structurotomy that cutting has been done up to an adequate depth? Yes, very good question. I think this question also comes up because people want to know, one, is it adequate cutting depth? And secondly is, what is the end point? So how far you should cut? So I think for us, and we have defined this in the paper also, if you have an impassable stricture to the scope, be it adult scope or pre-adult scope, and you are able to cut the stricture circumferentially or let's say radial or horizontally, and now you are able to advance your scope through, so that means you have achieved your technical success. Okay? That is what we in the group defined as. For me personally, I like to see as much of scar tissue cut out from me as possible. So I like to cut deep in the submucosal space, keep cutting the scar tissue. Obviously, you as an endoscopist has to be very comfortable that this is the submucosal plane, and now I'm reaching the muscle. Obviously, don't touch the muscle plane. So, you know, for us, for at least me, for myself, I can speak, I like to remove as much scar tissue as possible. Because the whole premise of endoscopic stricture ought to be why it is better than balloon dilatation. I mean, that's the debate, or why should we do it? So if you think of balloon dilatation, I always tell my patients also, balloon dilatation is like stretching a rubber band. Stretching a rubber band for 30 seconds in the endoscopy room, and then letting the elastic go. At some point, the scar tissue will still go back to where it was. That's why in balloon dilatation at the end of three years, 60% patients require surgery. The stricture ought to be you are not stretching it, but your job is to ensure all the scar tissue is cut through and you discard it. Now, the new scar tissue might grow in whatever years it might grow, but you as an endoscopist ensure that. So adequacy of stricture will be when your scope passes through, whatever scope you choose, PEDS or adult colonoscopy in your practice. Once you've done that, you are free to stop at that point because you have achieved what you started to do. But for me personally, I would like to see all the submucosal scar tissue to be gone on the endoscopic image. Dr. Shen, what would you say? Yes. A lot of the questions for that, people say, can you use EOS to guide you? And actually, unfortunately, Crohn's disease with a primary structure or an asthmatic structure, there's no such thing called a layered structure. Because underneath the mucosa, you have the fibrosis in the submucosa, in the muscularis mucosa, in the muscularis propria. Basically, all the things lump together. I agree with this. When I do the stricture therapy, after I stricture cut, cut, cut, when I feel comfortable, I pass a scope through it without resistance, I'm happy, I pull the scope out. But in a certain situation, if the stricture is very thin, especially in the side-to-side and asthmatic structure, very thin, I cut horizontally, I can make the stricture very, very, very wide. And even cut to the whole wall. But I have a rescue plan. We have the exit, we call it, the surgeon has the exit strategy. You put the clip there. So that's when you do the stricture therapy. I think that Simran is right. It's a blunt dilatation. Basically, you displace the tissue. You didn't take the tissue out. Knife therapy, you basically take the tissue out. But I'm warning everybody here, if you do the endoscopic therapy for the stricture, the first time you do the stricture therapy, no matter what you do, the blunt dilatation or knife therapy, please take biopsies. I have a couple of the patients already had an asthmatic structure, long-chromed structure at the biopsy showed a cancer. So it looks like an asthmatic structure. So just be precaution. Any stricture long-term before you do any intervention, at least once a year, biopsy that area. If you come three months later, repeated endoscopy for the dilatation or knife therapy, you don't have to take another piece of the biopsy. But at the inception and then every year, you should take a biopsy. Thank you, Dr. Chen. And Dr. Goswami, thank you for some awesome presentations and discussion tonight. And to Dr. Dragunov as well. Any final points before we conclude tonight's presentation? Yes. And I would first like to thank ASG, yourself, Lyle here to make this possible. Events like this require a lot of background work. So thank you to you guys. And thank you to ASG, who's been very proactively under leadership of Dr. Dragunov trying to bring IBD in the forefront. So we're very thankful for that. As I mentioned, there are these guideline papers out. Dr. Chen and myself, we are very approachable. If somebody still wants to reach out to understand how to set up their practice, what to do, please feel free to reach out to us, whatever medium. We really want this to become as mainstream as possible. We are trying to work with leading various conferences coming next year, where we will try to offer hands-on courses and things like that. So idea is for people to get more and more comfortable with this and to bring it to their practices. But once again, thank you so much. And please do not hesitate to reach out to any one of us. Thank you. Thank you. Thank you, Dr. Chen. In closing, thank you to everybody who participated in tonight's presentation. Again, just a quick reminder that before you log off, we would really appreciate if you provide us your feedback in the evaluation on the webinar. You can do this in the networking lounge. The evaluation form only takes about a minute to complete, and we'd really appreciate that. This does conclude our presentation for this evening. We do hope this information is useful for you and your practice. As a reminder, you can access the recording of this webinar by logging on to CIE by going to learn.ase.org. You do not have to be an ASE member to access this content, as our goal is to provide open access information and education from our Thursday webinar topic as a resource to assist gastroenterologists globally in improving their practices. I'll make the final slide there. Thank you very much. Our next webinar will be next Thursday. Please log on to that. That is going to be for our Spanish-speaking colleagues that are around the globe, so we would encourage you to all participate. We look forward to hearing from you again. Thank you all for your participation again tonight, and have a good night. Thank you. Good night. Bye.

training

accreditation

IBD

patient care

mentorship

global standard

healthcare professionals

strictureotomy

balloon dilation

scar tissue

injectable steroids

self-expanding metal stents

3D printing