00:00:00: Hello, everyone.

00:00:01: My name is Agli and I'm the host of UG Podcast, educational and hopefully fun dive into GI world and beyond.

00:00:08: We're very happy to have you with us today to reflect on all of the marvelous things that happen in Berlin.

00:00:14: And today's topic is endoscopy.

00:00:18: It is my utmost pleasure to introduce today's guest, an expert in quality and safety in endoscopy, a passionate educator, consultant gastroenterologist at Seathmarks in London, and a force to be reckoned Manmit Mathuro.

00:00:32: Welcome, Manmit.

00:00:33: Thank you, Agnes, for your kind introduction.

00:00:35: It's an honor to be here.

00:00:36: We are very happy to have with us and discuss what happened in Berlin.

00:00:42: So how did you like this year's UGE week?

00:00:45: Well I thought the UAG was a phenomenal meeting and I must be honest I haven't been for some time to UAG and I recall when I was invited to present my research as a research fellow some years back and what an honour it was to be on stage presenting novel research.

00:01:00: so I found it incredibly exciting.

00:01:02: It's really nice to be in a more comprehensive GI meeting to see how endoscopy fits in the wider world of gastroenterology, surgery, IBD and it was very diverse.

00:01:14: huge opportunities for collaboration and networking and a really energising meeting.

00:01:19: I really enjoyed it.

00:01:20: Most definitely.

00:01:22: Have you seen something that really caught your eye as something emerging in endoscopy?

00:01:28: Yeah, so when I was thinking about this, I got this idea of these new trends, these themes that were emerging, and this idea of precision endoscopy.

00:01:37: So we all know that we have lots of endoscopy that we need to do, but we can't keep up with demand.

00:01:42: And as endoscopy evolves to be more advanced in its techniques and technology, the risks also increase.

00:01:49: And this concept of knowing when not to do endoscopy.

00:01:52: So this idea of patient selection and lesion selection and being bit smarter with our characterization was a theme that I really liked.

00:02:02: And considering this, I'd like to reflect on Matt Rutter's paper where he talks about how to select patients who may have limited life expectancy for advanced therapeutic, you know, polypectomy.

00:02:14: And I think this is a really important trend because we have an ever-increasing demand for endoscopy with an aging, comorbid frail population potentially, and therefore knowing when not to do an endoscopy for a patient and when to divert our resource more appropriately, I think is a really, really important aspiration for us as an endoscopy community.

00:02:35: And it also ties in with the current themes of green endoscopy and green gastroenterology as well.

00:02:41: And we are also starting to do the research of how can we save our planet in the future.

00:02:48: Absolutely.

00:02:48: I mean, less is more.

00:02:50: And I think it's concept of doing a high quality index procedure, you know, rather than doing repeated unnecessary surveillance is a better way to sort of target our resource.

00:03:00: And I think similarly, you know, we have to think about which patient populations are at higher risk.

00:03:06: And I was really struck by the theme of the IBD surveillance colonoscopy, which is an interest of mine.

00:03:13: It was really nicely presented in the postgraduate course as well as, you know, subsequently in the meeting.

00:03:18: about how do you risk stratify these patients?

00:03:21: How do you work out which ones are gonna have those advanced lesions?

00:03:24: We know dysplasia is really, really difficult still to find despite the increases in AI, chromoendoscopy, digital, chromoendoscopy, that actually we still miss lesions.

00:03:36: So thinking about how we can maybe be a bit more organized about that, it was interesting.

00:03:42: There was quite an interesting paper that I saw about, and this is not novel, but very important work about how increasing throughout your list, the ADR may drop.

00:03:52: So this concept of our performance negatively impacted by fatigue.

00:03:57: And therefore, you know, we must think if we have an IBD surveillance list, how do we organize that to make sure we get the best performance, the best endoscopy, the best bowel preparation, the most appropriate time to do these procedures really effectively.

00:04:12: So I think how can we really use the science it's presented in?

00:04:16: UEG to really make sure that we have the best clinical benefits for our patients when we go back home.

00:04:22: Yeah, I think this is very well reflected in the clinical practice.

00:04:26: At least in my work, I see that sometimes people are followed up every year for a thing that they might undergo an EUS once and then you could have a definitive diagnosis instead of just seeing a submicoral lesion growing one millimeter per year?

00:04:44: Exactly.

00:04:45: It's the same concept and I think not only from the endoscopy perspective when we think about cost, resource, patient safety, but also I think we have to put ourselves in the shoes of our patients.

00:04:57: There's significant anxiety coming from an endoscopy procedure, there's significant preparation, there's you know time off work and you know family commitments and this idea of, you know, I know in radiology there's this concept of scan anxiety, you know, when you have follow-up CT scans, do you have recurrence of cancer?

00:05:16: And in a way, we may subject our patients to that in endoscopy as well.

00:05:19: So I think we have to be mindful of the patient experience as well.

00:05:23: As well as every intervention means a risk of complication.

00:05:27: Absolutely.

00:05:28: So having in mind this trend that you foresee that we will focus on, has anything Struct to you that will change your personal practice.

00:05:39: Yeah, I think there was another theme that emerged through many of the talks that were presented

00:05:44: about

00:05:45: how actually cold is the new hot.

00:05:47: So thinking about safety, again, you know, lesions that may be suitable for effective cold snares section.

00:05:54: over conventional EMR.

00:05:56: Because actually, if you employ this technique correctively and efficiently, it can be really safe and can be reasonably definitive.

00:06:04: Yes, there were some studies that showed that the recurrence rates might be slightly higher.

00:06:09: But actually, if you think about what I refer to as patient selection, lesion selection, in certain patients where safety is more important than longer term recurrence, you may opt for a cold snap resection technique to minimize some risk.

00:06:25: of, say, bleeding or immediate complications, particularly when you think about these concepts of frailty, comorbidity, anticoagulation, which actually really can change the way your patients outcomes are after your procedure.

00:06:38: And so I think Evelyn Decker presented very nicely on this when she was talking to us so eloquently about SSLs and actually having that really good view of the lesion, the overview, not just looking at the splastic nodule that might be the obvious thing, but actually looking at the extent of that.

00:06:55: And if you see that the SSL area could be resected with cold snare, you may be more definitive for the dysplastic area with EMR.

00:07:03: So being a bit more smarter about your approach.

00:07:06: And I think Michael Burke also reflected on the fact that cold snare is a very effective technique if it's done well, but often because it's deemed to be quite simplistic, people aren't trained very well in actually doing a cold snare.

00:07:20: So this concept of taking your first bite with a margin of normal tissue and then really seating the snare in, pressing down, suctioning to get a really nice slow closure and then working like a reverse jigsaw.

00:07:35: Actually, if you employ this technique correctly, you know, it can be quite effective, but often people may not do that.

00:07:42: And I think that leads on to my sort of big passion of training.

00:07:46: And, you know, throughout UEG, you know, we We saw sort of exemplars of how we should train residents and other endoscopies into these techniques and there are some fantastic resources now online and digitally as well as at meetings to help with this.

00:08:02: So I think one of the things I took away actually is to go back to basics to see how do my trainees, how do my fellows actually learn endoscopy because it's very different to how we did.

00:08:15: So thinking about immersing yourself in the online platforms that might be available and seeing where people get their information from is important.

00:08:23: It also ties to one of the endoscopy themes of the past years is education and actual standardization of both education, quality parameters and quality meters that we need to achieve.

00:08:38: What do you think is changing in this regard?

00:08:40: Are we focusing more on numbers or techniques?

00:08:44: How do we do this then?

00:08:45: So it's a really good question.

00:08:47: I think there's a lot of variation within Europe as to how we may train.

00:08:51: But I think what is universal is that we all agree that there should be quality assurance for the procedure that we do, whether it's ERCP, colonoscopy, upper-giantoscopy.

00:09:02: We have a lot of value and respect for quality assurance for the outcomes, our key performance indicators.

00:09:08: However, I don't think we pay equal weight to the quality assurance of that training process because how can you have one without the other?

00:09:15: And in the UK, we're very fortunate.

00:09:17: We have a very structured system with a joint advisory group, which gives us a really formalised structure to help training with a combination of hands-on, online, small-based teaching, and essentially a mentorship process whereby you're given structured feedback in the form of what we call the directly observed procedural assessment form.

00:09:38: So there's a really good format available through that and others can adopt that.

00:09:43: And of course this now has been augmented with simulation training as well as online resources.

00:09:50: What I like about this is that it kind of helps with the equality of training.

00:09:55: You know, everyone can access online resources, no matter which country or which unit you train in.

00:10:00: You don't have to be in a tertiary expert centre and therefore accessing these educational tools online, such as those available through the ESG Academy and fantastic courses like those that are offered against the Geeks course, they give you a really nice opportunity to sort of really ensure you're getting that high quality training.

00:10:20: I've just had a thought.

00:10:21: Coming back to your insights about the precision medicine and maybe getting back to basics and lesses more concept, does this mean that we're actually switching our mindset on what are pertinent outcomes in endoscopy?

00:10:37: Rather than focusing solely on radical rejection, we're beginning to contextualize it in patient care and quality of patient care.

00:10:48: their

00:10:48: experience

00:10:49: and thinking more globally rather than just our zero-resection.

00:10:56: I think you make a really valid point.

00:10:57: I think our zero-resection is obviously the goal, but my colleague, Fress Brown Saunders, makes this comment that I really believe in treat the patient, not the polyp.

00:11:08: So textualising the polyp within the patient is really important.

00:11:13: And I think as endoscopists, we have to be mindful that we are clinicians, not technicians.

00:11:18: And actually, we need to think about the context of that patient, you know, what does this polyp and the progression mean for this particular patient?

00:11:26: What is their risk?

00:11:27: What is their ability to tolerate this procedure?

00:11:30: What are the suitable alternatives?

00:11:32: Would a conservative approach actually be better here?

00:11:35: Or actually, do they need something more definitive like surgery?

00:11:38: And therefore, I think I come back to this treat the patient on the polyp because it from getting tunneled visioned about just thinking about technical resection outcomes and you know all of those things which we know we can get a bit distracted by.

00:11:53: and that's where you know quality assurance metrics such as the Pollock meeting where you can actually have a multidisciplinary discussion.

00:12:00: review the histology review the radiology.

00:12:02: think about the patient wishes you know talk about which reception technique might be optimal or sedation strategy and what are the risks.

00:12:11: you know how have they been and consented for this.

00:12:14: Are they going into this with their eyes fully opened?

00:12:17: I think those are crucial parts of our endoscopy care.

00:12:20: Quite excited to get back to basics now.

00:12:23: One more thing.

00:12:24: What was the most interesting eye-opening, maybe shocking or even confusing talk that you have seen?

00:12:34: Well, I think that's a really interesting... There were so many interesting tools, but what I wanted to reflect upon was... how inspirational the plenary was.

00:12:44: And, you know, whilst it might not be groundbreaking, but I was really struck by Matthias Lewis' initial comment of, you know, to be a good leader, you have to be a follower.

00:12:54: So there's something in this story about back to basics that even the leaders that we see up on the stage in sort of top top seats, you know, value this concept of followership.

00:13:04: So I think that's really important for us.

00:13:06: just to be grounded.

00:13:08: And on that, I'd like to sort of acknowledge the sort of lifetime achievement award that, you know, Lars Arbakan was awarded.

00:13:15: And he made a similar comment about how he was so grateful for the mentorship that he received during his endoscopy journey.

00:13:22: And he made a point about, it's my time to pay it forward and that we have this responsibility to future generations of endoscopists to say, hey, maybe you could join my research project, or have you thought about this, you know, quality improvement or this?

00:13:37: So actually, I like this idea of inspiring and supporting and encouraging the younger generation of endoscopists because ultimately their quality assurance is important because they're going to be doing your and my philosophy.

00:13:50: So we want to bring new people into the fold.

00:13:52: We have a very brilliant specialty and that I found very inspiring.

00:13:57: And on the same side, I found the talk about disinformation online with regards to social media incredibly powerful.

00:14:06: And this idea that if we look at where patients, the public and even medical community access their information, it's changing rapidly over time.

00:14:18: We can't just rely on PubMed and citations to get the message out.

00:14:22: People access information through social media channels, whether we agree with it or not.

00:14:29: And we know that this is an unregulated field and therefore... Actually, there can be a lot of misinformation that can be very damaging and confusing for patients.

00:14:38: And I liked this idea that was presented that actually as a medical community, this is our chance to have a responsibility to get in on that conversation and actually to educate our patients about what is really about, what colonoscopy involves, because unless we are there, the misinformation overtakes.

00:14:57: So that for me was quite a... you know, controversial talk, but it was actually really important because we can talk in our medical communities about quality assurance.

00:15:06: Yeah, this may be something isn't relevant to our patients.

00:15:10: So meet patients, meet trainees on the platforms that they like to communicate with because that's where we can maybe make a real impact.

00:15:17: Would I be correct in summarizing that this UG was more about personalized care and going back to basics, as you said, rather than cutting edge technology.

00:15:29: Of

00:15:30: course, I mean, these are the themes that I took away that were important for me.

00:15:35: And as you sort of mentioned, my interests are safety, quality education.

00:15:40: So I think these are my takes.

00:15:42: However, you know, there was lots of sort of advanced, you know, high cutting science that was presented.

00:15:48: And you know, it's always very impressive when you see, you know, young international experts presenting their abstracts, you know, not in their first language, doing a fantastic job.

00:15:59: And, you know, I know there was a Japanese study where they looked at how do we manage C-one cancers and the field about how endoscopy has a role and surgery has a role.

00:16:08: And the five year follow up was essentially looking at disease free survival as well as overall survival.

00:16:15: And There was this concept of how local recurrence and distant recurrence are essentially separate entities.

00:16:22: And obviously it was a Japanese experience.

00:16:24: Therefore, you know, the ESD experience is very good as you know.

00:16:28: But then.

00:16:29: we have to think how does that apply in my community, in my setting?

00:16:34: And what I took away from this very impressive study was actually that accepting sort of a safer technique that might not be as definitive might be more appropriate for the right patient selection.

00:16:46: And actually, if you get a good resection in a reasonably comorbid patient, they may take that as as good treatment and not worry about sort of distant metastases, because actually organ preservation is really important for quality of life for our patients.

00:17:04: and though it might not be a hundred percent perfect maybe this is good enough for this particular patient.

00:17:10: so bringing it back down to this concept of patient selection and the right technique for the right lesion for the right patient is what I took away from that.

00:17:19: Great.

00:17:19: So never mind the AI or cutting edge technology or a cold snare patient care.

00:17:24: It's at a front

00:17:25: row.

00:17:26: For me, that was has to come first because there will always be lots of new developments and we are, you know, seeing this rapidly emerging in the field of endoscopy.

00:17:35: But the key is, you know, there was this concept.

00:17:38: I just had an image of, you know, in World War Two, there was this concept in these types of too much playing for one man to fly where essentially the test test flight crashed because the technology was so advanced, but the pilot forgot to release the brake.

00:17:55: So this concept of you can have very fancy endoscopy kit, very big tools, very big knives, very interesting reception techniques, but ultimately you have an endoscopist.

00:18:06: and a team that have to make sure that we employ those judiciously and appropriately for that patient.

00:18:12: and that brings me to my sort of other big passion of teamwork in endoscopy.

00:18:16: so I'm very keen to follow all of these advances and it's really important that we keep up to date with these.

00:18:23: but ultimately putting them back into clinical practice has to be done in a considered and a safe way.

00:18:30: and often you know those tools need to be employed with a really good team, a really good setup to make the best of them.

00:18:37: otherwise they can be quite dangerous and expose patients to more risk particularly if they are newer emerging technologies where we have limited experience.

00:18:47: A lot to think about and digest after a UG week.

00:18:51: Thank you Manmeet.

00:18:52: so, so much for sharing your insights and will we see you in Barcelona

00:18:56: next year?

00:18:57: Absolutely, I look forward to it very much and thank you very much for the invitation, I really appreciate

00:19:01: it.

00:19:02: Thank you all for tuning in and we will see you in the next one.

00:19:06: Bye.