Video Q&A Session Play Pause Volume Quality 1080P 720P 640P Fullscreen Captions Transcript Chapters Slides Q&A Session Overview Back to Symposium Page I have a question for Alex actually, uh Alex in patients with limited disease, you see either he or left sided, do you recommend to take biopsies above the endoscopic margin? Right. And what should we do with the results of these biopsies? For instance, if you find um histological inflammation, even though there is no endoscopic activity, would you recommend more intensive therapy in those patients? And certainly uh a whole combined with topical. So, um so that's a tough question. So, uh you know, in our study of, of left sided colitis patients, um they uh the majority of them um just stayed as you see. Um let me show they didn't extend it. Yes. So, um actually, no, they, it, they were more likely to have proximal disease extension and that, that was shown with some other studies as well. We also showed that about 10% of them actually ended up uh being re diagnosed as Crohn's Disease. Um Now, that's not the majority still have U C uh but the risk of a change of diagnosis to Crohns disease is significant. Now, um some previous studies had only looked at endoscopically, endoscopically defined inflammation. Um we only uh used patients that had histologically defined inflammation. Um, but um, we, we, we did it on, you know, in patients that had, that had been biopsied in areas that were suspected to have information. In other words, I don't think, I don't think we know what this, what the outcome would be if patients get random, quote, unquote, random biopsies above the proximal edge of the disease just to find that histology. So confirmation if it's not there, these were all suspected to have some inflammatory patch. Uh What we did is we just confirmed it histologically and only used those patients that had the confirmation. Uh You know what I mean? So I don't think, I don't think it's, I don't know if it's worth sort of going fishing around with random bis to find that that left side of patch. But if it's, if you do, you know, obviously you're gonna do a full colonoscopy and if you see a patch around the appendix or in the gum and you biopsy, um and it's, and it's active, then it's, it's important to just keep in mind that this may uh have a uh approximal extension uh down the line and some of them might actually become, become cros the majority will stay as you see. Of course. So the definition doesn't change the left side of collis with ac or, and the seal patch is still, you see until proven otherwise. No, but uh this is amazing, Alex because I now when I'm seeing your data, I'm thinking maybe in those patients is limited with patch may, maybe we should start some um um more intensive therapy and immediately start some biology code instead of leaving them on uh on. These were all, these were all escalated, these were all escalated long term. Um I'm guessing I, I didn't tease it out or whether they were, the therapy was escalated because of their symptoms or because of the finding of the patch. I'm guessing it was because of the symptoms. So they require some sort of escalation of therapy. Anyway, I'm gonna add something to this a bit. I, I I'm wondering if there's something in the background here that you're noticing when their dose escalated. I will say that if I do see a sequel patch in someone, I do consider that a worrisome clinical sign that I'm more likely to progress toward more intensive therapy in those patients, especially in the younger patient. I do find that they're uh clinically less stable but there is a question for you, Jim um in a patient who is attenuated fat and she's high risk patient with both bounds. Having been cho concern. Do we go for section or we choose surveillance for next few years? Ok. So I'm sorry, what was the pathology was it? Oh, I'm sorry. Yeah, I'll bring that right up. Sorry about. Oh yeah. Wow. So um yeah, FA P in and of itself is, uh that's worrisome. And I'll tell you, I, I actually think, and this is something that Alex and I have talked about. Uh, and Noam Harpaz and I have, have touched on one of the risk ratifications that we miss out on an I B D all the time is sort of unrecognized lynch syndrome in these patients. Uh We just don't even know that it's going on until suddenly they develop sort of serial dysplasias and then, then the tissue is further tested and, and I'm gonna tell you the, the, at least half of the colorectal cancers that I picked up in the last 15 years have been lynch. So somebody has uh uh fab I'm, that is somebody who's gonna really, I'm gonna have my bright headlights on for them. You're gonna be getting regular. Yeah, you agree. Right. I agree. We've actually had, I mean, now we, you know, we almost have a series of patients with FA B plus U C or uh Lynch plus U C. Um um I think in most cases, uh well, in most cases, the Lynch was discovered sort of at the time of cancer already. So it's kind of difficult to tell how they would have progressed if left on their own. Um uh but it's an interesting problem. I agree with you. They tend to be, uh uh sort of harder. Um They, they tend to be more of, you know, high risk patient Yeah. And, and again, there's no data to suggest that using, for example, chromoendoscopy is gonna be helpful for the uh fa P patients. It just, there's no data on sporadic or on FA P that it's helpful. But for um yeah, I mean, an fa P patient needs to be very, very closely watched and I think the uh inclination be, should be toward um uh colectomy. One interesting thing is that I remember dog and when I was younger was that, you know, fa P patients just didn't get pait. That was commonly said, well, it ends up, I've got a few patients with either Poit or cros like disease of their post fa p uh pouches. So just remember that's probably not necessarily a a dogma that will stand. Professor Marion. There is a question from the audience about uh if patient got no discrete lesions on the surveillance colonoscopy but newly diagnosed with P S C. So you do like random biopsies even if there is no discrete lesions on the like chroma endoscopy. That's an excellent question because that to me is, you know, again, the P S C patients, I take extra care with those patients are gonna be getting a yearly uh surveillance. Those patients will be getting a chromoendoscopy with me every single year even if it looks bland and benign and nothing is going on. The one instance where I do believe a random biopsy is useful uh is in the P S E patient who has really burnt out tubular, unable to get a really good on PHOS view. And it tends to be in the distal colon more than anywhere else. Those patients, I, I don't think, I, I think we're kidding ourselves. If we think our ability to see the mucosal lining is actually gonna protect the patient in those patients. I do every 5 to 10 centimeters biopsies. Uh If I'm not able to get a really good on, I really do just two bites. It's all regional, but it's a visual exam. I spend the bulk of the exam just looking. Uh And that's, that's my approach to it. Thank you very much. And the question a little bit of, of a complication in this um uh There is now a bunch of papers in the pathology literature uh describing what is called nonconventional dysplasia in I B D. Um These are lesions that we were all sort of suspecting. They were probably suspecting they were probably dysplastic. Some of them actually have uh the abnormalities um that suggest that there probably are early dysplasias. Um These were in the past mostly diagnosed as indefinite dysplasia, maybe indefinite, probably positive. Um But there's now a bunch of papers suggesting that these are, you know, and discussions that in our meetings. So there's probably gonna be a switch in the rate of dysplasia diagnosis because pathologists are gonna start calling these dysplasias. Now, um that will on the flip side mean that perhaps the rate of progression will actually go down a little bit because these were previously grouped with the indefinite that have, as we know a lot, a lower rate of uh um uh progression. Interestingly enough, there's a couple of papers that suggest that those are more likely to be invisible. I don't know if that data has actually sort of uh been uh reproduced and most of it is coming from U CS F, the pathologist at U CS F. Um So I'm wondering Jim, what you think if you know, if now we have sort of a new, a new animal of, of so-called nonconventional dysplasia that tends to be more invisible. And obviously, the, the cave there is, we have to make sure what kind of endoscopy was done in those studies and whether it was chroma and et cetera uh or by other experts. Um Do you think that sort of throws uh any, any additional problems in the discussion of picking random bis or not? No, I actually, I, I invite the, you know, uh I, I, I really am intrigued by this because uh one I'm not a big fan of using the word invisible because if it's invisible, then there's really nothing we can do because random biopsy will not work. The target is too small. And I also want to move away from sort of dismissing it as sort of the new apparent cryos. I, I think some of our younger G I S won't remember this, but those were the focus of immense concern and worry about colorectal cancer risk and, you know, average risk patients and it, except it probably doesn't mean very much at all. Um So before, you know, I think the idea here is if we have another tool where we can look at some of these findings, see whether or not they're visible because frankly if they're not visible, then we shouldn't be scoping them hoping that we're going to protect them. We need to be realistic about what it is. We're offering our patients with these scopes and what I what I would hate to do, we're already doing over 2600 colonoscopies to find one dysplasia, which is ridiculous or one cancer. That's ridiculous. Uh Then I wanna make sure that we're not just putting patients through this added burden of surveillance to look for something that we have no hope of seeing, right? Or very little likelihood of picking up with random biopsy unless we're back to doing, you know, 100 and eight biopsies in every, you know, um related Jim. I wanted to ask you in a patient with P S E the example that was given um what if they have active colitis? So, you know, I missed you a bit uh repeat what you said. Can you hear me now? Yeah. Yeah. Um So in that patient with P S C who has active colitis and you're scoping them for displeasure, surveillance. But uh but there is inflammation. So in that context, would you then treat them? And once they've achieved once they are in endoscopic or deep permission, scope them again because you can't uh look for displeasure as well when there's active inflammation. Right? Yeah, it's so funny. You should ask that question. Mon I think we just shared a patient with this. Uh And yeah. So yeah, the, so the answer to that question is yes, I think uh especially if it's a first if it's a screening exam. And I think the other interesting sort of data point that a lot of people uh may have uh forgotten from all of the chroma literature where they were really keeping track of screening versus surveillance. The highest likelihood of finding a dysplasia is in that screening exam, right? So you want to optimize it, you want it to be a good exam, you want them to be in a remission if possible. And again, most of the P S C patients in my experience at least is that they're not so active, it's not so bad, but like our, our uh uh our lovely professor who we just took care of, uh he was quite active. So I would, I would get him on something quickly and then plan on something within about 4 to 6 months to repeat the test, you know, give him, give him a good opportunity to get into a real remission. Um, Jim, um, I, I don't know if there are other questions. Um, I have two practical questions for you. Are you an advocate of threat to target, meaning threat to East remission in order to prevent dysplasia and concern? Do you think we have enough data for that? Waiting for the result of the prospective trial? So, very practical. Are you maintaining patients on amino? Where, when, when they are on Biology or Jack? Because of the ons uh effect of the medications that could be uh that could exist outside its impact on the inflammation? Yeah. So yes, I I'm gonna say for now, I am always, I view histologic healing that sort of treat to target as sort of an ideal and I agree with you. The data is not in yet. I totally agree, but I do love getting the report back from Alex saying that it is histologically normal. Yeah. But am I actually serving that patient and preventing their colon cancer going forward? I think the jury is still out on that. But I do, I do ideally like to see them in as deep a remission as possible, especially if they've had a previous dysplasia. So from a practical standpoint, yes, I do, I, I I aim for that or I encourage my referring physicians to get them better. Now, a lot of my referring physicians and I'm gonna transition over to the mesalamine. There are a ton of mesalamines still being used in this country, particularly for, uh, ulcerative colitis. But there are still a few Crohn's hands, uh, hangers on and it's very frustrating for all of us. Most of these patients get better on one of the bigger gun medicines. One of the biologics or Jack, he and they hang on to their mesalamine. It's almost like a teddy bear. They, they, they don't want to let it go. And the gastroneurologists often are the same way. You probably have seen this too. Sean Fred. I don't think the data that we have for anti neoplastic benefit of mesalamines from, you know, I think some of Tom Allman's data showing that dysplasia didn't progress. Uh It was a very different world back then and I'm not even sure I buy that it worked all that great in those patients. This isn't fluoride, it's not preventing cavities. So I, I don't necessarily keep it on it if I've gotten them better with a biologic or with a, um with a Jack High inhibitor, I usually encourage them just to get, do, get down to monotherapy. I don't know. Is that your practice too? Yeah, I, I, I must say that when the patients are doing well, I tend not to change anything. The Irishman and me is very superstitious as well. No, no, because the point that we publish data as far as efficacy showing that biologics plus five is not more effective than biology alone and then you, you can stop but for the anti new effect, I'm still uh I, I still, I don't know uh uh Alex. Uh Yes. Any questions from the Yes, I, I have a couple more questions. The one of them regarding the modality of chroma endoscopy, you mentioned that a little bit about like me and blue and like what we mean by endoscopy like indigo carmine is very popular in Ukraine, something like aesthetic acid being used in Ukraine. And the other question about like virtual chromoendoscopy with like this NBI and things like that. Yeah. So the problem with NBI is that it makes everything darker and I think darker is not good. I think the less we're able to see then you just can't see as much. So I actually find that NBI in my own experience, I don't and the pit pattern has never been pit pit pattern uh validation has, has never been validated uh with NBI ever. So people are using Kudo pit pattern descriptions with NBI. I that's not based on anything, right? So the reason I felt the the reason that I started with methylene blue is that it was cheaper, right? It was much cheaper than in the Indigo Carmine and it had an added benefit of not just being a contrast stain like Integral Carmine, but it has an add a diss or so it actually after about 60 seconds, it is that Methylxanthine Studio like with la, you know, everybody see these laxative colons, right? You know, the, the the the uh that process allows the abominate tissue or dysplastic tissue to stand out. So it's just another means for definition. However, integra carmine and methylene blue are equivalent in terms of the data. So if you know whatever you have use, I find that you keeping it lighter is better. If it's too dark, it's just too dark, you wanna be able to have enough blue to overcome our ability to our inability to distinguish depth in orange red wavelengths. That is a biologic sort of trait that we can overcome in terms of our visual uh uh ability uh abilities, right? So the blue adds depth. Thank you very much. And there is actually another question about the uh Kudo pit pattern and it's getting more and more popular in Ukraine to the describe like Anoma. Uh But in I B D, what's the role how you like put this pit pattern uh picture into the general like view of how you describe and how you like risk stratify? Do you think like I know that the original article is like this is, this is like oh grade disposal, this is high grade dysplasia. This is so I go one through four uh I those are really the most common issues. And again, if it's hyperplastic, you, you still get dots, right? Everybody knows the dots that you see in the white halo that's accentuated when you have the blue on there. And the, the lesion is defined better when you get to the level two, you're really getting more to an aema. So you can actually see irregularity, but you're not getting to level three yet. Level three is where you get to that more cerebra form. It's more of a brain appearance, right? So once you have a type three, uh it is incredibly uh useful and picking up uh genuine dysplasia. Type two is really usually more edema. And that's why more active disease really subverts the quality of the exam. Once that cerebra form appearance becomes less organized, which is a type four, right? Then that's when you start getting into a higher grade of dysplasia or carcinoma. So I think for people who are just starting to use this, you look at the original, I mean, and they're all online at this point. Look at the Kudo 123 and four. Don't start getting into R and the, the this type one or just 123 and four. Once you do that and start practicing that, start incorporating that into your reports and then start looking at the correlation. But I think um that's as far people getting, you don't have to do a facial report and you're not, you know, loading into an A I machine, you just need to just distinguish between dysplastic or not dysplastic. Thank you very much. And uh there is another question about this uh a clinical trial for E S D in uh uh I B D and some like, this is very, obviously very inspiring and like, very optimistic about the future of like E S D in I B D. But some data is hard to believe like the uh procedure time of 93 minutes, I think, like, and block reaction more than 95%. That's very optimistic. And, but at the same time it's very hard to, to believe that that's like an actual American study too because the best paper would, went out somewhere in Japan probably. But, uh, I, yeah, that, that's very, like, inspiring. Yeah, it's inspiring. And also it's almost, um, you know, for me, you know, I, I, I'm pretty efficient in the endoscopy unit but I spend time with the team, the advanced endo team and they're brilliant and they do an amazing job and they all, they do so many of the, it, it's, you know, it's really, it's a, it's a sight to behold. And I, I think if somebody is an advanced endoscopist and they're interested in learning how to do this, I would love to connect them with our advanced folks and maybe we can get something done uh, to help, uh, spread the word on this and sort of see how they've managed to incorporate this into the s really, it's a scheduling issue more than anything else. I mean, no one wants to spend eight hours doing a, uh, an E S D when you could probably do a same day surgery, laparoscopically for these patients. Right. So, um, but I think that would be, I'd be very happy to, uh, to work with you on that. Anybody who's interested. Thank you. And I think the last question I got, if we still have a minute, um, the question is, um, about post surgical, uh, surveillance colonoscopy. Let's say if someone got ileal reaction and started on medications after that and everything kind of fine, uh, when you do a screening after the surgery. So if you're looking for a recurrence of their Crohn's disease in my own practice, I look at two things. One is, what was their history prior to the surgery? Right. Had they gone 25 years, uh, to the point where they needed the surgery and now they've had their surgery. I put them on a postoperative preventive regimen, you know, an anti T N F, what have you, uh, and now I need to check for a recurrence in that setting. I think it's safe to wait 9 to 12 months. I usually wait 9 to 12 months to look again. If somebody has a more aggressive history, meaning, you know, it's happening more frequently or they went very, uh, they have a phenotype that's more vitalizing. They've had an abscess, uh, they're only two years out from their initial diagnosis. Then that's somebody that I might bring in is six months to look for evidence of a recurrence. Um uh So I I it's a range anywhere from 6 to 12 months, but it's imperative to look. And I also, and this is something that John Fred uh taught me early on is that the staging or the restaging of a patient postoperatively really needs to be a 3 60. And that's not just necessarily a colonoscopy. I'll often throw in an M R enterography. If you have a really good M R Ander in your institution, it's very helpful to have all of that data uh within the first year of surgery. So, uh yeah, or intestinal ultrasound. Exactly. Exactly. Alex. We are, yeah, we are, we are, we are using more and more and actually even we are doing after three months, you know, I mean, not yet certain that it's useful but we are monitoring even before the six months mark with a and more and more with. Yeah. And I think what, what surprised me about like we, one of our, I think on our second meeting, we got a discussion about the management of uh uh acute severe colitis and ultrasound is modality useful in this setting too. It's also kind of amazing and helps a lot. I mean, it's, it's still, yeah, I understand. I know that Mike. Mike is very enthusiastic but uh it's, I mean, it's, it's, it's preliminary, you know, and um for instance, for uh we will need a study like Z can study where we will, uh, escalate patients based on the finding, uh, instead of just escalating based on biomarker to see if actually it matters, you know, because so far it's a lot of association studies. Right. Right. So we have, we have to be cautious and the patients look, yeah, patients love it. Right. And I think, I think they radiated, they love it. I think I like why, why I'm optimistic about intestinal ultrasound in Ukraine in particular, because in the resource limited settings, when like high definition endoscopes, like I was surprised by the slide, about 2023% still using the old definition. But in Ukraine, it's probably 95% still using old definition. But Alex, if I may, Ukraine is in advance as compared to us for yes, that it's, it's still, it's still under work in progress. I would say, I know, I think it's very promising, you know, uh in US has been introduced basically one year or two years ago and there are still many centers in the US who with without. So, so it's a cultural difference between Europe and the US and Alex. If I can say something, just judging from the tenor and quality of the questions that I've gotten today, uh the resolution of the scope is less important than the clarity of the mind, looking at the images that any given scope is projecting. So uh if the neurons aren't there at the other end, then no, if the highest resolution scope can help you. Uh But it sounds like you guys are doing great in that department. Really? OK. Thank you. That's, that's uh going back to our first uh presentation. That's all about mindset. OK. Thank you. Thank you very much. Uh Alex, I have one question maybe to an uh from Italy about the recording. So the recording of all those talks uh will be available. And actually, I'm, I'm working with um uh to build a kind of uh compressed file with all the recording from, from the beginning. I think we may have something like uh I can't remember. This is number four, right? Yes, that's number four. And I actually answered vitali and to everyone, yes, recordings of the previous sessions are available and um this recording also will be available. We have like uh 16 talks uh available. OK, good. Yeah, I, I don't think I have any more questions. At least at my reach at this moment. I will uh definitely reach to our presenters if I will receive after later feedback because I, I'm doing some background work on interpreting these slides and um given some additional context in Ukrainian. So I, that's a possibility that I will reach to you with additional questions a little bit later. But uh Alex, what was uh uh using? She used a live, uh I think that's a new feature in in Zoom. I will ask her specifically. I've seen this feature too. Um It was amazing because Louis uh Louis was immediately translated in Ukraine. Was it good? It was decent. It was like help to understand in general, but it's like artificial intelligence. So it's like work in progress. It's limitations. But I think it, it, it can be helpful and it, it, it is useful. Yeah, it's definitely jokes don't translate probably. Ok, guys. Excellent. Thank you so much. Thank you. Thank you, everybody. Uh We are all thinking about you. Uh Hope to see you soon, maybe some of some of you you if you are able to travel again. And uh I want to thank all the speaker Jim Alex. Thank you so much, Laurie and Mike who are with us today. Thank you very much. Bye. Thank you. Bye bye. Have a nice day. Bye. Published June 16, 2023 Created by Featured Faculty Jean-Frederic Colombel, MD Professor of Medicine (Gastroenterology)Mount Sinai Health System View full profile
