Gowthami Ramar

[Turki @tmhamed]

@ScopingSundays @GowthamiR01 @EHolzwanger @BilalMohammadMD @AhmadBazarbashi @CarlKayMD @vaibhav_manu @RobertoSimonsMD @JosephHabibi_MD @AdvaniRashmiMD @TrieuMD @LizzieAbyMD @rmulkimd @KennethParkMD @enaddawod @NCosgroveMD @ziommed @DouglasAdlerMD @AgnihotriGI @SyedGerdezi @TennysonMD @TomTielleman @SanchezLunaMD @PerelmansPearls @DrMohdZein @MouhannaMDGI @shifaumarMD @AriBensonMD @lashagog @NEndoscopy #ScopingSunday #GITwitter

[Turki @tmhamed]

@ScopingSundays @GowthamiR01 @EHolzwanger @BilalMohammadMD @AhmadBazarbashi @CarlKayMD @vaibhav_manu @RobertoSimonsMD @JosephHabibi_MD @AdvaniRashmiMD @TrieuMD @LizzieAbyMD @rmulkimd @SunilAminMD @KMonkemuller @DCharabaty @SultanMahmoodMD @AgnihotriGI @drdalbir Submucosal Tunneling with Endoscopic Submucosal Resection (STER)
#ScopingSunday #GITwitter
@RKeswaniMD @SunilAminMD @MendozaLadd @som_krishna @DannyIssaMD @AThakerMD @APrabhuMD @AnotherPatelMD @jenmarankimd @neilRsharmaMD

[Turki @tmhamed]

@ScopingSundays @GowthamiR01 @EHolzwanger @BilalMohammadMD @AhmadBazarbashi @CarlKayMD @vaibhav_manu @RobertoSimonsMD @JosephHabibi_MD @AdvaniRashmiMD @TrieuMD @LizzieAbyMD @rmulkimd @SyedGerdezi @TomTielleman @EndoscopyOthman @GiJawaid @SahajRathi @SanchezLunaMD @ShyamTMD @DavidDiehlMD @neilRsharmaMD @BalissMichelle @VinayChandraMD @GI_Pearls @Taalamri @DharJahnvi @KM_Pawlak @gastrowala @AgnihotriGI @laurenkhanna Fourth layer SELs are a distinct entity due to their malignant potential; main differential being GIST, Leiomyoma and Schwannoma.

AGA guidelines: SEL arising from muscularis propria should be sampled (preferably using FNB or FNA)

#ScopingSunday #GITwitter

[Turki @tmhamed]

@ScopingSundays @GowthamiR01 @EHolzwanger @BilalMohammadMD @AhmadBazarbashi @CarlKayMD @vaibhav_manu @RobertoSimonsMD @JosephHabibi_MD @AdvaniRashmiMD @TrieuMD @LizzieAbyMD @rmulkimd @SyedGerdezi @TomTielleman @EndoscopyOthman @GiJawaid @SahajRathi @SanchezLunaMD @ShyamTMD @DavidDiehlMD @neilRsharmaMD @BalissMichelle @VinayChandraMD @GI_Pearls @Taalamri @DharJahnvi @KM_Pawlak @gastrowala @AgnihotriGI @laurenkhanna @JovaniManol @NEndoscopy @doc_zubin @SriGaddamMD @thedennischen @PopovVioleta @RashidLui @tberzin @DrSaeeeed ⭕️Hyperenhancement and avascular area (necrosis) in GIST lesions
⭕️ Hypoenhancement in leiomyomas
➡️allow for accurate discrimination between the 2 lesions, with accuracy greater than 95% #ScopingSunday #GITwitter

[Erik Holzwanger, MD, ABOM-D @HilarHolzy]

@BilalMohammadMD @tmhamed @ScopingSundays @GowthamiR01 @AhmadBazarbashi @CarlKayMD @vaibhav_manu @RobertoSimonsMD @JosephHabibi_MD @AdvaniRashmiMD @TrieuMD @LizzieAbyMD @rmulkimd @SyedGerdezi @TomTielleman @EndoscopyOthman @GiJawaid @SahajRathi @SanchezLunaMD @ShyamTMD @DavidDiehlMD @neilRsharmaMD @BalissMichelle @VinayChandraMD @GI_Pearls @Taalamri @DharJahnvi @KM_Pawlak @gastrowala @AgnihotriGI @laurenkhanna @JovaniManol @NEndoscopy @doc_zubin @SriGaddamMD @thedennischen @PopovVioleta @RashidLui @tberzin @DrSaeeeed @Jarshah4 @RobertBechara @MendozaLadd @DennisYangMD @MoamenGabrMD EFTR is great for lesions 2.5cm or less, however can't do in esophagus/cardia/areas requiring significant retroflexion

STER is nice for these lesions that don't fit into EFTR consideration (mainly studied in upper GI tract with esophagus/cardia, has been done in lower GI tract)

[Turki @tmhamed]

@ScopingSundays @GowthamiR01 @EHolzwanger @BilalMohammadMD @AhmadBazarbashi @CarlKayMD @vaibhav_manu @RobertoSimonsMD @JosephHabibi_MD @AdvaniRashmiMD @TrieuMD @LizzieAbyMD @rmulkimd @SunilAminMD @KMonkemuller @DCharabaty @SultanMahmoodMD @AgnihotriGI @drdalbir @stevenbollipo @drkeithsiau @SyedGerdezi @SChandanMD @DrBakhitMD @NeilBhogalMD @DavidDiehlMD @MendozaLadd @neilRsharmaMD @TheGastrologer @Samir_Grover @TomasDaVee @KMonkemuller @drKumarGI @MahamHayatMD @KatieFalloonMD @JamesHaddadMD @AmmaraKhalidMD @drsethinyc @DrSaeeeed

[Turki @tmhamed]

@ScopingSundays @GowthamiR01 @EHolzwanger @BilalMohammadMD @AhmadBazarbashi @CarlKayMD @vaibhav_manu @RobertoSimonsMD @JosephHabibi_MD @AdvaniRashmiMD @TrieuMD @LizzieAbyMD @rmulkimd @SunilAminMD @KMonkemuller @DCharabaty @SultanMahmoodMD @AgnihotriGI @drdalbir Choice of technique is based mainly on the involvement of the muscularis propria, the size/location and the experience of the operator

STER and EFTR tend to be the mainstay 🔥🔥🔥

[Turki @tmhamed]

@ScopingSundays @GowthamiR01 @EHolzwanger @BilalMohammadMD @AhmadBazarbashi @CarlKayMD @vaibhav_manu @RobertoSimonsMD @JosephHabibi_MD @AdvaniRashmiMD @TrieuMD @LizzieAbyMD @rmulkimd @KennethParkMD @enaddawod @NCosgroveMD @ziommed @DouglasAdlerMD @AgnihotriGI @SyedGerdezi @TennysonMD @TomTielleman @SanchezLunaMD @PerelmansPearls @DrMohdZein @MouhannaMDGI @shifaumarMD Key Point: Scary things do live beneath the surface as well!
#ScopingSunday #GITwitter

@KennethParkMD @enaddawod @NCosgroveMD @ziommed @DouglasAdlerMD @AgnihotriGI @TrieuMD @AriBensonMD @lashagog @NEndoscopy

[Turki @tmhamed]

@ScopingSundays @GowthamiR01 @EHolzwanger @BilalMohammadMD @AhmadBazarbashi @CarlKayMD @vaibhav_manu @RobertoSimonsMD @JosephHabibi_MD @AdvaniRashmiMD @TrieuMD @LizzieAbyMD @rmulkimd @KennethParkMD @enaddawod @NCosgroveMD @ziommed @DouglasAdlerMD @AgnihotriGI

[Turki @tmhamed]

@ScopingSundays @GowthamiR01 @EHolzwanger @BilalMohammadMD @AhmadBazarbashi @CarlKayMD @vaibhav_manu @RobertoSimonsMD @JosephHabibi_MD @AdvaniRashmiMD @TrieuMD @LizzieAbyMD @rmulkimd BONUS CASE TWEET!!

40 year old with 30 lbs unintentional weight loss over 2 months found to have this intramural lesion below. What do you think it is?
#ScopingSunday #GITwitter

Tag: @KennethParkMD @enaddawod @NCosgroveMD @ziommed @DouglasAdlerMD @AgnihotriGI

[Turki @tmhamed]

@ScopingSundays @GowthamiR01 @EHolzwanger @BilalMohammadMD @AhmadBazarbashi @CarlKayMD @vaibhav_manu @RobertoSimonsMD @JosephHabibi_MD @AdvaniRashmiMD @TrieuMD @LizzieAbyMD @rmulkimd @SunilAminMD @KMonkemuller @DCharabaty @SultanMahmoodMD @AgnihotriGI @drdalbir On a systematic review for FTR including a total of 1539 patients.
Indications difficult to resect benign lesions (66.2%), T1 ADK (25.6%), neuroendocrine tumor (6.1%).
Technical success rate 89%
R0 achieved 79%
Perforation (2%), Bleeding (5%)
Recurrence at 3 months (8%)

[Turki @tmhamed]

@ScopingSundays @GowthamiR01 @EHolzwanger @BilalMohammadMD @AhmadBazarbashi @CarlKayMD @vaibhav_manu @RobertoSimonsMD @JosephHabibi_MD @AdvaniRashmiMD @TrieuMD @LizzieAbyMD @rmulkimd @SunilAminMD @KMonkemuller @DCharabaty @SultanMahmoodMD @AgnihotriGI @drdalbir You are performing a Lower EUS for an SEL. Findings showing an 18 mm, 4th layer, hypoechoic lesion with high risk feature. The lesion is ulcerated and slowly oozing. What would you do next? #ScopingSunday #GITwitter

[Mohammad Bilal, MD @BilalMohammadMD]

@tmhamed @ScopingSundays @GowthamiR01 @EHolzwanger @AhmadBazarbashi @CarlKayMD @vaibhav_manu @RobertoSimonsMD @JosephHabibi_MD @AdvaniRashmiMD @TrieuMD @LizzieAbyMD @rmulkimd @SyedGerdezi @TomTielleman @EndoscopyOthman @GiJawaid @SahajRathi @SanchezLunaMD @ShyamTMD @DavidDiehlMD @neilRsharmaMD @BalissMichelle @VinayChandraMD @GI_Pearls @Taalamri @DharJahnvi @KM_Pawlak @gastrowala @AgnihotriGI @laurenkhanna @JovaniManol @NEndoscopy @doc_zubin @SriGaddamMD @thedennischen @PopovVioleta @RashidLui @tberzin @DrSaeeeed @Jarshah4 This lesion perhaps to large for endoscopic resection, but curious when experts chose free hand EFTR vs STER vs surgery for SELs ?

@EHolzwanger @RobertBechara @MendozaLadd @DennisYangMD @AdvaniRashmiMD @MoamenGabrMD @neilRsharmaMD @AhmadBazarbashi @TomTielleman

[Erik Holzwanger, MD, ABOM-D @HilarHolzy]

@BilalMohammadMD @drkeithsiau @tmhamed @ScopingSundays @GowthamiR01 @AhmadBazarbashi @CarlKayMD @vaibhav_manu @RobertoSimonsMD @JosephHabibi_MD @AdvaniRashmiMD @TrieuMD @LizzieAbyMD @rmulkimd @GKochharMD @stevenbollipo @SyedGerdezi @SChandanMD @DrBakhitMD @NeilBhogalMD @DavidDiehlMD @MendozaLadd @neilRsharmaMD @TheGastrologer @NikhilKumtaMD @SunilAminMD @KMonkemuller @drKumarGI @MahamHayatMD @KatieFalloonMD @JamesHaddadMD @AmmaraKhalidMD @drsethinyc @KTossapol @ZachSmithGI @DeMadaria @UzmaSiddiquiMD @RKeswaniMD @mswaghden @som_krishna @DannyIssaMD @AnotherPatelMD @DCharabaty @JennPhanMD @DouglasAdlerMD @MoamenGabrMD Definitely depends on the size and layer/layers it is involving. Most commonly in the submucosa, so if small enough cap band EMR may be sufficient. Otherwise if concern for deep submucosa/large lesion can consider ESD or muscularis propria can consider STER

Can't do FTRD here 😢

[Tom Tielleman, MD @TomTielleman]

@EHolzwanger @tmhamed @ScopingSundays @GowthamiR01 @BilalMohammadMD @AhmadBazarbashi @CarlKayMD @vaibhav_manu @RobertoSimonsMD @JosephHabibi_MD @AdvaniRashmiMD @TrieuMD @LizzieAbyMD @rmulkimd @ShimaghavimiMD @pritesh_mutha @drkeithsiau @SChandanMD @EndoscopyOthman @buxbaum_l @ChahalPrabhleen @drKumarGI @AnandSahaiEUS @DavidDiehlMD @neilRsharmaMD @TheGastrologer @Samir_Grover @SanchezLunaMD @MouhannaMDGI @ShyamTMD @DrWaqarAhmed1 @KMonkemuller @iGUT_Houston @DCharabaty @SultanMahmoodMD @AgnihotriGI @drdalbir @mayyismail @MahamHayatMD @alhaddad_mo @AmyOxentenkoMD @MPGN46 @brianjacobsonmd @mikewallacemd @SaadAlrajhi @NikhilKumtaMD Also anyone taking boards, testing the layers will almost certainly be your EUS question. You’ll get lesion off 4th layer and be given CD117 positive or negative and asked what it is.

[Turki @tmhamed]

@ScopingSundays @GowthamiR01 @EHolzwanger @BilalMohammadMD @AhmadBazarbashi @CarlKayMD @vaibhav_manu @RobertoSimonsMD @JosephHabibi_MD @AdvaniRashmiMD @TrieuMD @LizzieAbyMD @rmulkimd 🔥Marginal halo sign => Schwannoma.
🔥3rd or 4th layer
🔥Schwannoma is of neural origin, along with neuroma and neurofibroma
🔥Most commonly located in the body of the stomach
🔥Histology: Negative for CD117, desmin, α-SMA and positive for S100
#ScopingSunday #GITwitter

[Mohammad Bilal, MD @BilalMohammadMD]

@EHolzwanger @tmhamed @ScopingSundays @GowthamiR01 @AhmadBazarbashi @CarlKayMD @vaibhav_manu @RobertoSimonsMD @JosephHabibi_MD @AdvaniRashmiMD @TrieuMD @LizzieAbyMD @rmulkimd @ShimaghavimiMD @pritesh_mutha @drkeithsiau @SChandanMD @EndoscopyOthman @buxbaum_l @ChahalPrabhleen @drKumarGI @AnandSahaiEUS @DavidDiehlMD @neilRsharmaMD @TheGastrologer @Samir_Grover @TomTielleman @SanchezLunaMD @MouhannaMDGI @ShyamTMD @DrWaqarAhmed1 @KMonkemuller @iGUT_Houston @DCharabaty @SultanMahmoodMD @AgnihotriGI @drdalbir @mayyismail @MahamHayatMD @alhaddad_mo @AmyOxentenkoMD @MPGN46 @brianjacobsonmd @mikewallacemd @SaadAlrajhi @NikhilKumtaMD One of the best ways to examine layer of origin in EUS I learned from the amazing @MSawhneyMD is to aspirate all the air, put water in the lumen which allows better separation of layers to allow better visualization of layer of origin

[Mohammad Bilal, MD @BilalMohammadMD]

@tmhamed @ScopingSundays @GowthamiR01 @EHolzwanger @AhmadBazarbashi @CarlKayMD @vaibhav_manu @RobertoSimonsMD @JosephHabibi_MD @AdvaniRashmiMD @TrieuMD @LizzieAbyMD @rmulkimd @ShimaghavimiMD @pritesh_mutha @drkeithsiau @SChandanMD @EndoscopyOthman @buxbaum_l @ChahalPrabhleen @drKumarGI @AnandSahaiEUS @DavidDiehlMD @neilRsharmaMD @TheGastrologer @Samir_Grover @TomTielleman @SanchezLunaMD @MouhannaMDGI @ShyamTMD @DrWaqarAhmed1 @KMonkemuller Great points @tmhamed - changing the position can help in so many situations in #GIEndoscopy and often under utilized

[Erik Holzwanger, MD, ABOM-D @HilarHolzy]

@tmhamed @ScopingSundays @GowthamiR01 @BilalMohammadMD @AhmadBazarbashi @CarlKayMD @vaibhav_manu @RobertoSimonsMD @JosephHabibi_MD @AdvaniRashmiMD @TrieuMD @LizzieAbyMD @rmulkimd @ShimaghavimiMD @pritesh_mutha @drkeithsiau @SChandanMD @EndoscopyOthman @buxbaum_l @ChahalPrabhleen @drKumarGI @AnandSahaiEUS @DavidDiehlMD @neilRsharmaMD @TheGastrologer @Samir_Grover @TomTielleman @SanchezLunaMD @MouhannaMDGI @ShyamTMD @DrWaqarAhmed1 @KMonkemuller @iGUT_Houston @DCharabaty @SultanMahmoodMD @AgnihotriGI @drdalbir @mayyismail @MahamHayatMD @alhaddad_mo @AmyOxentenkoMD @MPGN46 @brianjacobsonmd @mikewallacemd @SaadAlrajhi @NikhilKumtaMD 🔥Anyone starting EUS🔥

Understanding wall layers is the most critical foundation to identifying and developing differentials for SELs, so definitely save this image 😊

[Turki @tmhamed]

@ScopingSundays @GowthamiR01 @EHolzwanger @BilalMohammadMD @AhmadBazarbashi @CarlKayMD @vaibhav_manu @RobertoSimonsMD @JosephHabibi_MD @AdvaniRashmiMD @TrieuMD @LizzieAbyMD @rmulkimd @ShimaghavimiMD @pritesh_mutha @drkeithsiau @SChandanMD @EndoscopyOthman @buxbaum_l @ChahalPrabhleen @drKumarGI @AnandSahaiEUS @DavidDiehlMD @neilRsharmaMD @TheGastrologer @Samir_Grover @TomTielleman @SanchezLunaMD @MouhannaMDGI @ShyamTMD @DrWaqarAhmed1 @KMonkemuller @iGUT_Houston @DCharabaty @SultanMahmoodMD @AgnihotriGI @drdalbir @mayyismail EUS reveals a 5-layer pattern numbered from the lumen out: first and second (mucosa including the muscularis mucosa), third (submucosa), fourth (MP), and fifth (serosa or adventitia)
#ScopingSunday #GITwitter