00:00:00: Egle Dieninyte: Hello everyone, my name is Egle and I'm the host of UEG Podcasts.

00:00:04: Egle Dieninyte: educational and hopefully fun dive into GI world and beyond.

00:00:07: Egle Dieninyte: We're very happy to have you with us for another exciting episode.

00:00:11: Egle Dieninyte: So today we're still in Barcelona, it's the last day of UEG week which was very very exciting.

00:00:16: Egle Dieninyte: And we are talking about the best of UEG week in endoscopy.

00:00:21: Egle Dieninyte: For this I'm very very happy to introduce our expert in the interventional EUS,

00:00:26: Egle Dieninyte: a master of connecting things from the within.

00:00:29: Egle Dieninyte: Just give him a long enough guide wire.

00:00:32: Egle Dieninyte: Dr. Giuseppe Vanella from Milano.

00:00:34: Egle Dieninyte: Welcome to UEG Podcasts Giuseppe.

00:00:36: Giuseppe Vanella: Hello, hello everybody and thank you for having me.

00:00:40: Giuseppe Vanella: It's a pleasure to share with you some insights or what let's say

00:00:45: Giuseppe Vanella: was outstanding for me into this congress in the realm of endoscopy.

00:00:51: Egle Dieninyte: Let's start big.

00:00:52: Egle Dieninyte: How was UEG week for you?

00:00:54: Giuseppe Vanella: Okay, it was busy as always but also interesting as always because I think the main difference

00:01:00: Giuseppe Vanella: between this congress and some others is that you have a real multidisciplinary connection.

00:01:07: Giuseppe Vanella: So for people like us who are concentrated on a research focus,

00:01:12: Giuseppe Vanella: sometimes staying outside the comfort zone and be involved in discussion with surgeons,

00:01:17: Giuseppe Vanella: interventional radiologists, other people in the GI field, they can provide you

00:01:23: Giuseppe Vanella: with some perspective that you are not used to receive in a specialised congress.

00:01:28: Giuseppe Vanella: So it's definitely an environment where you want

00:01:31: Giuseppe Vanella: to have your research discussed and present because the feedback

00:01:36: Giuseppe Vanella: you receive here it's very very important for the future

00:01:40: Giuseppe Vanella: of your research and in general the future of GI research.

00:01:44: Giuseppe Vanella: That is also true for endoscopy.

00:01:46: Egle Dieninyte: Indeed.

00:01:47: Egle Dieninyte: So where were there any studies or presentations that really shook you?

00:01:53: Egle Dieninyte: Because as you said the perspectives presented here are very varied.

00:01:58: Egle Dieninyte: So what stuck out for you?

00:02:00: Giuseppe Vanella: Okay, so first thing is really nice to see that in the complex field

00:02:06: Giuseppe Vanella: of gastrointestinal research endoscopy stands out as top abstract.

00:02:12: Giuseppe Vanella: So it's interesting to see that you don't need to speak about advanced technology but you can ask

00:02:19: Giuseppe Vanella: yourself very simple questions and this brings innovation into the endoscopy practice and GI practice.

00:02:26: Giuseppe Vanella: As for example among the top abstracts the one which was chosen for the

00:02:31: Giuseppe Vanella: plenary session was the trial on antibiotics in cholangitis, the COBRA trial.

00:02:36: Giuseppe Vanella: I think if I can recall the name.

00:02:39: Giuseppe Vanella: So this question there is very very simple.

00:02:42: Giuseppe Vanella: After achieving adequate source control in cholangitis for distal obstruction do we need

00:02:49: Giuseppe Vanella: to complete the course of antibiotic up to seven days

00:02:53: Giuseppe Vanella: or we can shorten the interval of antibiotics to one day?

00:02:58: Giuseppe Vanella: And that's a very simple question which was answered with a large randomised trial from the Dutch group,

00:03:05: Giuseppe Vanella: more than 400 patients, and they were able to demonstrate

00:03:08: Giuseppe Vanella: that basically clinical success and clinical cure were similar.

00:03:13: Giuseppe Vanella: But of course the adverse events from the antibiotic course were fewer in the shortened interval group.

00:03:22: Giuseppe Vanella: So of course it's a very selective population of people improving without fever after ERCP,

00:03:31: Giuseppe Vanella: without immunocompromised background, so no complex stricture and whatever.

00:03:39: Giuseppe Vanella: But it's a signal that we need to reply very simple questions to innovate the daily practice of our patients.

00:03:48: Giuseppe Vanella: Of course this doesn't apply to hilar strictures or whatever

00:03:52: Giuseppe Vanella: but it's something interesting that we need still to design trials like that.

00:03:58: Egle Dieninyte: So it's also interesting that this was selected for plenary session because this is a paradigm

00:04:05: Egle Dieninyte: that we lived for like decades and still we questioned some things

00:04:09: Egle Dieninyte: that were fundamental and like we do it like this.

00:04:12: Egle Dieninyte: And in regards to very interventional advanced stuff, what stood out?

00:04:19: Giuseppe Vanella: So of course this one on antibiotics, it's a large-scale implementation trial,

00:04:25: Giuseppe Vanella: but to me the most compelling and challenging evidence into

00:04:29: Giuseppe Vanella: endoscopy at this congress was the TESLA trial, another Dutch study.

00:04:34: Giuseppe Vanella: Basically the question was how do we treat patients with malignant hilar stricture?

00:04:40: Giuseppe Vanella: because nowadays our guidelines suggest that you can use endoscopy

00:04:44: Giuseppe Vanella: or radiological intervention in a complementary way.

00:04:49: Giuseppe Vanella: Exactly, expertise, what's available at your institution and whatever, the type of strictures of course.

00:04:57: Giuseppe Vanella: But there has been increasing space for endoscopy in the last years.

00:05:02: Giuseppe Vanella: But this trial challenges this assumption because they randomise patients

00:05:07: Giuseppe Vanella: to receive primary stenting via interventional

00:05:11: Giuseppe Vanella: radiological access with uncovered metal stents, suprapapillary,

00:05:16: Giuseppe Vanella: where at risk of cholangitis compared to standard ERCP practice.

00:05:21: Giuseppe Vanella: And they demonstrated that the rate of adverse events were lower in the group of interventional radiology,

00:05:30: Giuseppe Vanella: 40% versus 70% if I can recall, but especially the rate of cholangitis was much lower,

00:05:38: Giuseppe Vanella: 3% versus more than 30% in the endoscopic group.

00:05:42: Giuseppe Vanella: So this is something that really challenges our actual practice.

00:05:47: Giuseppe Vanella: But I should say that they compared of course a very optimised radiological treatment

00:05:54: Giuseppe Vanella: which is not the standard of care nowadays because it's really rare to have percutaneous stenting

00:06:01: Giuseppe Vanella: in the first session with a suprapapillary metal stent

00:06:05: Giuseppe Vanella: versus an heterogeneous endoscopic practice with plastic,

00:06:09: Giuseppe Vanella: metal, suprapapillary, transpapillary stenting and whatever.

00:06:14: Giuseppe Vanella: So it's definitely something that opens new scenarios where endoscopy needs

00:06:19: Giuseppe Vanella: to demonstrate that standardisation is required for the endoscopic practice.

00:06:24: Giuseppe Vanella: And maybe these also challenges and pushes interventional radiology

00:06:28: Giuseppe Vanella: to standardise their practice towards primary stenting of the hilum.

00:06:33: Giuseppe Vanella: But definitely we need to change the paradigm that transpapillary is the way.

00:06:39: Giuseppe Vanella: And for challenging this paradigm, we can also have other routes now.

00:06:43: Giuseppe Vanella: We have the EUS-guided biliary drainage.

00:06:46: Giuseppe Vanella: And also in this congress, we have several abstracts trying to, as for example,

00:06:51: Giuseppe Vanella: demonstrate the feasibility of transmural drainage with hepaticogastrostomy

00:06:56: Giuseppe Vanella: or even hepaticoduodenostomy in complex hilar strictures.

00:07:00: Giuseppe Vanella: So innovation comes this way, discussing our practice.

00:07:04: Egle Dieninyte: In these trials, do you think that we are comparing apples and oranges in some way?

00:07:09: Giuseppe Vanella: Definitely, definitely true.

00:07:12: Giuseppe Vanella: But still, the apples, are very good apples now.

00:07:17: Giuseppe Vanella: 3% of cholangitis in complex hilar strictures are very good outcomes.

00:07:22: Giuseppe Vanella: So this pushes us to find strategies that are comparable to those results.

00:07:29: Giuseppe Vanella: So even if it's not a practice changing evidence today,

00:07:33: Giuseppe Vanella: this is for sure something for endoscopists to say, okay, we need to achieve that rate of cholangitis.

00:07:40: Giuseppe Vanella: This means ameliorating our ERCP practice in terms also of opacification of drain segments

00:07:46: Giuseppe Vanella: to concentrate our efforts in stay in reducing the risk of cholangitis, pancreatitis, and whatever.

00:07:53: Giuseppe Vanella: And this might mean also transmural drainage for some patients EUS-guided transmural drainage.

00:07:59: Egle Dieninyte: So from what you were saying, it seems like this congress had some very, in terms of the methodology

00:08:07: Egle Dieninyte: or a question, very simple but fundamental studies, but also very high-end in terms of technology.

00:08:15: Egle Dieninyte: But what is the basic trend in endoscopy that you have seen in this congress that stuck out?

00:08:21: Egle Dieninyte: Because last year, maybe AI or bariatrics were very prevalent.

00:08:26: Egle Dieninyte: What's hot this year?

00:08:28: Giuseppe Vanella: Well, I think that generally speaking, and that's something that I like very much,

00:08:35: Giuseppe Vanella: we are seeing a shift from technical feasibility to clinical impact of what we introduce.

00:08:42: Egle Dieninyte: Patient outcomes.

00:08:43: Giuseppe Vanella: Patient outcomes.

00:08:44: Giuseppe Vanella: But even in the realm of AI, I have seen much more studies not concentrated

00:08:50: Giuseppe Vanella: on the performance of the model or whatever, the technology, but on trying to,

00:08:55: Giuseppe Vanella: as for example, provide real-time guidance for a procedure, something that,

00:09:01: Giuseppe Vanella: as for example, select better selection of patients for one procedure.

00:09:06: Giuseppe Vanella: So I've seen clearly a trend towards trying to answer more clinical questions.

00:09:12: Giuseppe Vanella: Just to go outside my pancreaticobiliary practice, as for example,

00:09:18: Giuseppe Vanella: very good trials have been produced in the realm of ESD in underwater versus standard gas-assisted ESD.

00:09:28: Giuseppe Vanella: This is not a new technology.

00:09:30: Giuseppe Vanella: This is simply trying to see if we can adapt what we have to our environment.

00:09:36: Giuseppe Vanella: Both of those trials, one was from the Humanitas group and one was

00:09:39: Giuseppe Vanella: in one other Italian group, come from the Western setting.

00:09:43: Giuseppe Vanella: So a setting where ESD practice has been more difficult to be implemented rather than Japan, for example.

00:09:50: Giuseppe Vanella: But these authors posed again a simple question.

00:09:53: Giuseppe Vanella: If we change the environment, and if we go underwater, can we improve our outcomes?

00:09:59: Giuseppe Vanella: And they were able to demonstrate that the composite outcome of R0 resection and safety,

00:10:05: Giuseppe Vanella: so adverse event, was better underwater rather than with gas-assisted ESD.

00:10:11: Giuseppe Vanella: In one trial, it was superior.

00:10:13: Giuseppe Vanella: In the other trial, the R0 resection was non-inferior, so comparable.

00:10:18: Giuseppe Vanella: And both studies found improved dissection time and also less bleeding events,

00:10:25: Giuseppe Vanella: less need for use of coagulation forceps.

00:10:29: Giuseppe Vanella: So it's something that says how we can ameliorate our practice

00:10:33: Giuseppe Vanella: to be more standardised, to provide better care for our patients.

00:10:38: Giuseppe Vanella: So I like when endoscopy poses these questions that improve quality and outcomes for patients.

00:10:47: Egle Dieninyte: Have you seen anything that you might, when you come back tomorrow to Milano,

00:10:52: Egle Dieninyte: will you try to implement in your practice?

00:10:56: Egle Dieninyte: The water?

00:10:57: Giuseppe Vanella: That's interesting.

00:10:58: Giuseppe Vanella: Okay, water, it's already something that is already there.

00:11:02: Giuseppe Vanella: I always use water-assisted colonoscopy.

00:11:07: Giuseppe Vanella: And now that I am also starting a bit of ESD, I go for underwater.

00:11:12: Giuseppe Vanella: But we are already using, for example, a lot of transmural drainage in complex hilar strictures.

00:11:21: Giuseppe Vanella: But I'm interested in the concept that many other groups are now trying

00:11:26: Giuseppe Vanella: to stay away from crossing the tumour or crossing the papilla.

00:11:31: Giuseppe Vanella: So this gives me the opportunity to consider much earlier the transmural drainage than before,

00:11:38: Giuseppe Vanella: of course, when you have experience in doing that.

00:11:42: Giuseppe Vanella: So I would say there's not a revolution that changes my practice tomorrow, but I can see a trend towards

00:11:49: Giuseppe Vanella: offering new solutions for these complex scenarios and this gives the direction for future research for sure.

00:11:58: Egle Dieninyte: Would you foresee any difficulties from a more global standpoint?

00:12:03: Egle Dieninyte: Because we talk a lot of becoming half surgeons,

00:12:06: Egle Dieninyte: being more interventional, doing more and more complex procedures.

00:12:10: Egle Dieninyte: But the guidelines clearly say that you need to have expertise, at least in the HPB field.

00:12:15: Egle Dieninyte: You need both ERCP and interventional EUS and you have to have the volume and expertise.

00:12:20: Egle Dieninyte: You need to be comfortable with both of the procedures.

00:12:24: Egle Dieninyte: And if we talk so much that this is the best thing for the patient and patient outcomes,

00:12:29: Egle Dieninyte: but the trials come from a very specialised high volume centres.

00:12:34: Egle Dieninyte: Is there a risk that we will start doing this in less voluminous centres

00:12:40: Egle Dieninyte: with less expertise and the outcomes might be detrimental to the patient?

00:12:46: Egle Dieninyte: I know that what you call this FOMO of EUS.

00:12:50: Giuseppe Vanella: Yes, yes, yes.

00:12:52: Giuseppe Vanella: Definitely a good point.

00:12:54: Giuseppe Vanella: This fear of missing out is something that we are now seeing in advanced interventional endoscopy.

00:13:02: Giuseppe Vanella: Of course, this can push individuals to search for specialised training pathways.

00:13:10: Giuseppe Vanella: And this is a good thing.

00:13:11: Giuseppe Vanella: But on the other end, we need to keep our boundaries on quality standardisation.

00:13:19: Giuseppe Vanella: And this is a responsibility for everyone,

00:13:22: Giuseppe Vanella: is a responsibility for societies to provide core curriculum and whatever.

00:13:28: Egle Dieninyte: Minimal requirements.

00:13:29: Giuseppe Vanella: Requirements, training courses and whatever.

00:13:32: Giuseppe Vanella: It's a responsibility for researchers because when we promote a study,

00:13:37: Giuseppe Vanella: we don't need to demonstrate the technical success of a procedure.

00:13:41: Giuseppe Vanella: We need to demonstrate what's the burden of complications for those patients.

00:13:46: Giuseppe Vanella: We need to demonstrate that long term outcomes are good.

00:13:50: Giuseppe Vanella: The patient reported outcomes, quality of life is involved in the decision making.

00:13:55: Giuseppe Vanella: So this is something that we really need to care.

00:14:00: Egle Dieninyte: It's a lovely note to end and we all need to get home after a very, very interesting UEG week.

00:14:07: Egle Dieninyte: Thank you everybody for tuning in.

00:14:09: Egle Dieninyte: Thank you, Giuseppe, for a very interesting talk.

00:14:12: Egle Dieninyte: And we will see everybody next year in Copenhagen.

00:14:16: Egle Dieninyte: Bye.