Turki #ScopingSundays Gowthami Ramar @EHolzwanger Ahmad Bazarbashi أحمد بازارباشي Carl Kay, MD Vaibhav Wadhwa Roberto Simons-Linares, MD Joseph Sleiman, MD, FACP Rashmi Advani, MD, ABOM Judy Trieu, MD, MPH Lizzie Aby, MD Ramzi Mulki, MD Shima Ghavimi Pritesh Mutha Keith Siau Saurabh Chandan, MD Mohamed Othman James L Buxbaum Prabhleen Chahal MD,MASGE,FACG Anand Kumar, MD MPH FASGE Anand Sahai David Diehl Neil Sharma, M.D. FASGE, FACG, AGAF Muddasir Ayaz Samir C. Grover, M.D. Tom Tielleman, MD Sergio A. Sánchez-Luna, MD, DABOM (He/Him/His) Mouhanna Abu Ghanimeh Shyam Thakkar, MD Dr Waqar Ahmed Klaus Mönkemüller, MD, PhD Great points Turki - changing the position can help in so many situations in #GIEndoscopy and often under utilized

#ScopingSundays Gowthami Ramar @EHolzwanger Mohammad Bilal, MD Ahmad Bazarbashi أحمد بازارباشي Carl Kay, MD Vaibhav Wadhwa Roberto Simons-Linares, MD Joseph Sleiman, MD, FACP Rashmi Advani, MD, ABOM Judy Trieu, MD, MPH Lizzie Aby, MD Ramzi Mulki, MD Shima Ghavimi Pritesh Mutha Keith Siau Saurabh Chandan, MD Mohamed Othman James L Buxbaum Prabhleen Chahal MD,MASGE,FACG Anand Kumar, MD MPH FASGE Anand Sahai David Diehl Neil Sharma, M.D. FASGE, FACG, AGAF Muddasir Ayaz Samir C. Grover, M.D. Tom Tielleman, MD Sergio A. Sánchez-Luna, MD, DABOM (He/Him/His) Mouhanna Abu Ghanimeh Shyam Thakkar, MD Dr Waqar Ahmed Klaus Mönkemüller, MD, PhD Nirav Thosani Aline Charabaty, MD, FACG, AGAF Sultan Mahmood MD Abhishek Agnihotri, MD Dalbir Sandhu, MD, FACG, FASGE Mayada Ismail, MD, ABOM 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

Turki #ScopingSundays Gowthami Ramar Mohammad Bilal, MD Ahmad Bazarbashi أحمد بازارباشي Carl Kay, MD Vaibhav Wadhwa Roberto Simons-Linares, MD Joseph Sleiman, MD, FACP Rashmi Advani, MD, ABOM Judy Trieu, MD, MPH Lizzie Aby, MD Ramzi Mulki, MD Shima Ghavimi Pritesh Mutha Keith Siau Saurabh Chandan, MD Mohamed Othman James L Buxbaum Prabhleen Chahal MD,MASGE,FACG Anand Kumar, MD MPH FASGE Anand Sahai David Diehl Neil Sharma, M.D. FASGE, FACG, AGAF Muddasir Ayaz Samir C. Grover, M.D. Tom Tielleman, MD Sergio A. Sánchez-Luna, MD, DABOM (He/Him/His) Mouhanna Abu Ghanimeh Shyam Thakkar, MD Dr Waqar Ahmed Klaus Mönkemüller, MD, PhD Nirav Thosani Aline Charabaty, MD, FACG, AGAF Sultan Mahmood MD Abhishek Agnihotri, MD Dalbir Sandhu, MD, FACG, FASGE Mayada Ismail, MD, ABOM Maham Hayat, MD Mohammad Al-Haddad, FASGE,FACG, AGAF Amy Oxentenko MD Manoel Galvao Neto MD, MSC, FASGE, IFASBMS Brian Jacobson Michael Wallace Saad Alrajhi-سعد محمد سعد الراجحي Nikhil Kumta, MD, MS 🔥Anyone starting EUS🔥 Understanding wall layers is the most critical foundation to identifying and developing differentials for SELs, so definitely save this image 😊

@EHolzwanger Turki #ScopingSundays Gowthami Ramar Ahmad Bazarbashi أحمد بازارباشي Carl Kay, MD Vaibhav Wadhwa Roberto Simons-Linares, MD Joseph Sleiman, MD, FACP Rashmi Advani, MD, ABOM Judy Trieu, MD, MPH Lizzie Aby, MD Ramzi Mulki, MD Shima Ghavimi Pritesh Mutha Keith Siau Saurabh Chandan, MD Mohamed Othman James L Buxbaum Prabhleen Chahal MD,MASGE,FACG Anand Kumar, MD MPH FASGE Anand Sahai David Diehl Neil Sharma, M.D. FASGE, FACG, AGAF Muddasir Ayaz Samir C. Grover, M.D. Tom Tielleman, MD Sergio A. Sánchez-Luna, MD, DABOM (He/Him/His) Mouhanna Abu Ghanimeh Shyam Thakkar, MD Dr Waqar Ahmed Klaus Mönkemüller, MD, PhD Nirav Thosani Aline Charabaty, MD, FACG, AGAF Sultan Mahmood MD Abhishek Agnihotri, MD Dalbir Sandhu, MD, FACG, FASGE Mayada Ismail, MD, ABOM Maham Hayat, MD Mohammad Al-Haddad, FASGE,FACG, AGAF Amy Oxentenko MD Manoel Galvao Neto MD, MSC, FASGE, IFASBMS Brian Jacobson Michael Wallace Saad Alrajhi-سعد محمد سعد الراجحي Nikhil Kumta, MD, MS One of the best ways to examine layer of origin in EUS I learned from the amazing Mandeep Sawhney 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

#ScopingSundays Gowthami Ramar @EHolzwanger Mohammad Bilal, MD Ahmad Bazarbashi MD أحمد بازارباشي Carl Kay, MD Vaibhav Wadhwa Roberto Simons-Linares, MD Joseph Sleiman, MD, FACP Rashmi Advani, MD, ABOM Judy Trieu, MD, MPH Lizzie Aby, MD Ramzi Mulki, MD 🔥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 Keith Siau Turki #ScopingSundays Gowthami Ramar Ahmad Bazarbashi MD أحمد بازارباشي Carl Kay, MD Vaibhav Wadhwa Roberto Simons-Linares, MD Joseph Sleiman, MD, FACP Rashmi Advani, MD, ABOM Judy Trieu, MD, MPH Lizzie Aby, MD Ramzi Mulki, MD Gursimran Kochhar MD Steven Bollipo Anjum Gardezi MD Saurabh Chandan, MD M. Bakhit MD Neil Bhogal, MD David Diehl Antonio Mendoza Ladd MD, AGAF, FACG, FASGE Neil Sharma, M.D. FASGE, FACG, AGAF Muddasir Ayaz Nikhil Kumta, MD, MS Sunil Amin, MD, FASGE, FRCPC Klaus Mönkemüller, MD, PhD Anand Kumar, MD MPH FASGE Maham Hayat, MD Katie Falloon James D. Haddad, MD, FACP Ammara Khalid Dr. Amrita Sethi Tos Kerdsirichairat Zach Smith Enrique de-Madaria @UzmaSiddiquiMD RKeswaniMD Mihir Wagh Somashekar Krishna, MD, MPH Danny Issa, MD Vaishali Patel, MD MHS Aline Charabaty, MD, FACG, AGAF Jenn Phan MD Douglas G. Adler MD, FASGE, FACG, AGAF Moamen Gabr 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 😢

@EHolzwanger Turki #ScopingSundays Gowthami Ramar Mohammad Bilal, MD Ahmad Bazarbashi أحمد بازارباشي Carl Kay, MD Vaibhav Wadhwa Roberto Simons-Linares, MD Joseph Sleiman, MD, FACP Rashmi Advani, MD, ABOM Judy Trieu, MD, MPH Lizzie Aby, MD Ramzi Mulki, MD Shima Ghavimi Pritesh Mutha Keith Siau Saurabh Chandan, MD Mohamed Othman James L Buxbaum Prabhleen Chahal MD,MASGE,FACG Anand Kumar, MD MPH FASGE Anand Sahai David Diehl Neil Sharma, M.D. FASGE, FACG, AGAF Muddasir Ayaz Samir C. Grover, M.D. Sergio A. Sánchez-Luna, MD, DABOM (He/Him/His) Mouhanna Abu Ghanimeh Shyam Thakkar, MD Dr Waqar Ahmed Klaus Mönkemüller, MD, PhD Nirav Thosani Aline Charabaty, MD, FACG, AGAF Sultan Mahmood MD Abhishek Agnihotri, MD Dalbir Sandhu, MD, FACG, FASGE Mayada Ismail, MD, ABOM Maham Hayat, MD Mohammad Al-Haddad, FASGE,FACG, AGAF Amy Oxentenko MD Manoel Galvao Neto MD, MSC, FASGE, IFASBMS Brian Jacobson Michael Wallace Saad Alrajhi-سعد محمد سعد الراجحي Nikhil Kumta, MD, MS 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.

#ScopingSundays Gowthami Ramar @EHolzwanger Mohammad Bilal, MD Ahmad Bazarbashi MD أحمد بازارباشي Carl Kay, MD Vaibhav Wadhwa Roberto Simons-Linares, MD Joseph Sleiman, MD, FACP Rashmi Advani, MD, ABOM Judy Trieu, MD, MPH Lizzie Aby, MD Ramzi Mulki, MD Anjum Gardezi MD Tom Tielleman, MD Mohamed Othman Salmaan Jawaid, MD Sahaj Rathi MD, DM, MRCP Sergio A. Sánchez-Luna, MD, DABOM (He/Him/His) Shyam Thakkar, MD David Diehl Neil Sharma, M.D. FASGE, FACG, AGAF Michelle Baliss, DO Vinay Chandrasekhara, MD GI Pearls Turki AlAmri |تُرْكي عبدالله الْعَمريَّ MD Jahnvi Dhar Katarzyna Monika Pawlak Aziz Aadam Abhishek Agnihotri, MD Lauren Khanna 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

#ScopingSundays Gowthami Ramar @EHolzwanger Mohammad Bilal, MD Ahmad Bazarbashi MD أحمد بازارباشي Carl Kay, MD Vaibhav Wadhwa Roberto Simons-Linares, MD Joseph Sleiman, MD, FACP Rashmi Advani, MD, ABOM Judy Trieu, MD, MPH Lizzie Aby, MD Ramzi Mulki, MD Anjum Gardezi MD Tom Tielleman, MD Mohamed Othman Salmaan Jawaid, MD Sahaj Rathi MD, DM, MRCP Sergio A. Sánchez-Luna, MD, DABOM (He/Him/His) Shyam Thakkar, MD David Diehl Neil Sharma, M.D. FASGE, FACG, AGAF Michelle Baliss, DO Vinay Chandrasekhara, MD GI Pearls Turki AlAmri |تُرْكي عبدالله الْعَمريَّ MD Jahnvi Dhar Katarzyna Monika Pawlak Aziz Aadam Abhishek Agnihotri, MD Lauren Khanna Manol Jovani, MD MPH Prof John Leeds Zubin Sharma MD Srinivas Gaddam, MD, MPH Dennis Chen Violeta Popov, MD PhD Rashid Lui 雷諾信 Tyler Berzin MD, FASGE Ahmed Saeed, MD, DABOM ⭕️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

Turki #ScopingSundays Gowthami Ramar @EHolzwanger Ahmad Bazarbashi MD أحمد بازارباشي Carl Kay, MD Vaibhav Wadhwa Roberto Simons-Linares, MD Joseph Sleiman, MD, FACP Rashmi Advani, MD, ABOM Judy Trieu, MD, MPH Lizzie Aby, MD Ramzi Mulki, MD Anjum Gardezi MD Tom Tielleman, MD Mohamed Othman Salmaan Jawaid, MD Sahaj Rathi MD, DM, MRCP Sergio A. Sánchez-Luna, MD, DABOM (He/Him/His) Shyam Thakkar, MD David Diehl Neil Sharma, M.D. FASGE, FACG, AGAF Michelle Baliss, DO Vinay Chandrasekhara, MD GI Pearls Turki AlAmri |تُرْكي عبدالله الْعَمريَّ MD Jahnvi Dhar Katarzyna Monika Pawlak Aziz Aadam Abhishek Agnihotri, MD Lauren Khanna Manol Jovani, MD MPH Prof John Leeds Zubin Sharma MD Srinivas Gaddam, MD, MPH Dennis Chen Violeta Popov, MD PhD Rashid Lui 雷諾信 Tyler Berzin MD, FASGE Ahmed Saeed, MD, DABOM Raj Shah This lesion perhaps to large for endoscopic resection, but curious when experts chose free hand EFTR vs STER vs surgery for SELs ? @EHolzwanger Robert Bechara Antonio Mendoza Ladd MD, AGAF, FACG, FASGE Dennis Yang, MD, FACG,AGAF,FASGE Rashmi Advani, MD, ABOM Moamen Gabr Neil Sharma, M.D. FASGE, FACG, AGAF Ahmad Bazarbashi MD أحمد بازارباشي Tom Tielleman, MD

#ScopingSundays Gowthami Ramar @EHolzwanger Mohammad Bilal, MD Ahmad Bazarbashi MD أحمد بازارباشي Carl Kay, MD Vaibhav Wadhwa Roberto Simons-Linares, MD Joseph Sleiman, MD, FACP Rashmi Advani, MD, ABOM Judy Trieu, MD, MPH Lizzie Aby, MD Ramzi Mulki, MD Sunil Amin, MD, FASGE, FRCPC Klaus Mönkemüller, MD, PhD Aline Charabaty, MD, FACG, AGAF Sultan Mahmood MD Abhishek Agnihotri, MD Dalbir Sandhu, MD, FACG, FASGE 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

#ScopingSundays Gowthami Ramar @EHolzwanger Mohammad Bilal, MD Ahmad Bazarbashi MD أحمد بازارباشي Carl Kay, MD Vaibhav Wadhwa Roberto Simons-Linares, MD Joseph Sleiman, MD, FACP Rashmi Advani, MD, ABOM Judy Trieu, MD, MPH Lizzie Aby, MD Ramzi Mulki, MD Sunil Amin, MD, FASGE, FRCPC Klaus Mönkemüller, MD, PhD Aline Charabaty, MD, FACG, AGAF Sultan Mahmood MD Abhishek Agnihotri, MD Dalbir Sandhu, MD, FACG, FASGE Steven Bollipo Keith Siau Anjum Gardezi MD Saurabh Chandan, MD M. Bakhit MD Neil Bhogal, MD David Diehl Antonio Mendoza Ladd MD, AGAF, FACG, FASGE Neil Sharma, M.D. FASGE, FACG, AGAF Muddasir Ayaz Samir C. Grover, M.D. R. Tomás DaVee MD, MSCI, FASGE Klaus Mönkemüller, MD, PhD Anand Kumar, MD MPH FASGE Maham Hayat, MD Katie Falloon James D. Haddad, MD, FACP Ammara Khalid Dr. Amrita Sethi Ahmed Saeed, MD, DABOM

#ScopingSundays Gowthami Ramar @EHolzwanger Mohammad Bilal, MD Ahmad Bazarbashi MD أحمد بازارباشي Carl Kay, MD Vaibhav Wadhwa Roberto Simons-Linares, MD Joseph Sleiman, MD, FACP Rashmi Advani, MD, ABOM Judy Trieu, MD, MPH Lizzie Aby, MD Ramzi Mulki, MD Sunil Amin, MD, FASGE, FRCPC Klaus Mönkemüller, MD, PhD Aline Charabaty, MD, FACG, AGAF Sultan Mahmood MD Abhishek Agnihotri, MD Dalbir Sandhu, MD, FACG, FASGE 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 🔥🔥🔥

#ScopingSundays Gowthami Ramar @EHolzwanger Mohammad Bilal, MD Ahmad Bazarbashi MD أحمد بازارباشي Carl Kay, MD Vaibhav Wadhwa Roberto Simons-Linares, MD Joseph Sleiman, MD, FACP Rashmi Advani, MD, ABOM Judy Trieu, MD, MPH Lizzie Aby, MD Ramzi Mulki, MD Sunil Amin, MD, FASGE, FRCPC Klaus Mönkemüller, MD, PhD Aline Charabaty, MD, FACG, AGAF Sultan Mahmood MD Abhishek Agnihotri, MD Dalbir Sandhu, MD, FACG, FASGE 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%)

#ScopingSundays Gowthami Ramar @EHolzwanger Mohammad Bilal, MD Ahmad Bazarbashi MD أحمد بازارباشي Carl Kay, MD Vaibhav Wadhwa Roberto Simons-Linares, MD Joseph Sleiman, MD, FACP Rashmi Advani, MD, ABOM Judy Trieu, MD, MPH Lizzie Aby, MD Ramzi Mulki, MD Sunil Amin, MD, FASGE, FRCPC Klaus Mönkemüller, MD, PhD Aline Charabaty, MD, FACG, AGAF Sultan Mahmood MD Abhishek Agnihotri, MD Dalbir Sandhu, MD, FACG, FASGE Submucosal Tunneling with Endoscopic Submucosal Resection (STER) #ScopingSunday #GITwitter RKeswaniMD Sunil Amin, MD, FASGE, FRCPC Antonio Mendoza Ladd MD, AGAF, FACG, FASGE Somashekar Krishna, MD, MPH Danny Issa, MD @AThakerMD Anoop Prabhu Vaishali Patel, MD MHS @jenmarankimd Neil Sharma, M.D. FASGE, FACG, AGAF

#ScopingSundays Gowthami Ramar @EHolzwanger Mohammad Bilal, MD Ahmad Bazarbashi MD أحمد بازارباشي Carl Kay, MD Vaibhav Wadhwa Roberto Simons-Linares, MD Joseph Sleiman, MD, FACP Rashmi Advani, MD, ABOM Judy Trieu, MD, MPH Lizzie Aby, MD Ramzi Mulki, MD 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: Kenneth Park, MD, MSc, DABOM Enad Dawod Natalie Cosgrove MD moiz ahmed Douglas G. Adler MD, FASGE, FACG, AGAF Abhishek Agnihotri, MD

#ScopingSundays Gowthami Ramar @EHolzwanger Mohammad Bilal, MD Ahmad Bazarbashi MD أحمد بازارباشي Carl Kay, MD Vaibhav Wadhwa Roberto Simons-Linares, MD Joseph Sleiman, MD, FACP Rashmi Advani, MD, ABOM Judy Trieu, MD, MPH Lizzie Aby, MD Ramzi Mulki, MD Kenneth Park, MD, MSc, DABOM Enad Dawod Natalie Cosgrove MD moiz ahmed Douglas G. Adler MD, FASGE, FACG, AGAF Abhishek Agnihotri, MD

#ScopingSundays Gowthami Ramar @EHolzwanger Mohammad Bilal, MD Ahmad Bazarbashi MD أحمد بازارباشي Carl Kay, MD Vaibhav Wadhwa Roberto Simons-Linares, MD Joseph Sleiman, MD, FACP Rashmi Advani, MD, ABOM Judy Trieu, MD, MPH Lizzie Aby, MD Ramzi Mulki, MD Kenneth Park, MD, MSc, DABOM Enad Dawod Natalie Cosgrove MD moiz ahmed Douglas G. Adler MD, FASGE, FACG, AGAF Abhishek Agnihotri, MD Anjum Gardezi MD Christina Tennyson MD Tom Tielleman, MD Sergio A. Sánchez-Luna, MD, DABOM (He/Him/His) Alex Perelman Mohamad El Zein MD, MPH  Mouhanna Abu Ghanimeh Shifa Umar, MD Key Point: Scary things do live beneath the surface as well! #ScopingSunday #GITwitter Kenneth Park, MD, MSc, DABOM Enad Dawod Natalie Cosgrove MD moiz ahmed Douglas G. Adler MD, FASGE, FACG, AGAF Abhishek Agnihotri, MD Judy Trieu, MD, MPH Ari Benson @lashagog Prof John Leeds

Mohammad Bilal, MD Turki #ScopingSundays Gowthami Ramar Ahmad Bazarbashi MD أحمد بازارباشي Carl Kay, MD Vaibhav Wadhwa Roberto Simons-Linares, MD Joseph Sleiman, MD, FACP Rashmi Advani, MD, ABOM Judy Trieu, MD, MPH Lizzie Aby, MD Ramzi Mulki, MD Anjum Gardezi MD Tom Tielleman, MD Mohamed Othman Salmaan Jawaid, MD Sahaj Rathi MD, DM, MRCP Sergio A. Sánchez-Luna, MD, DABOM (He/Him/His) Shyam Thakkar, MD David Diehl Neil Sharma, M.D. FASGE, FACG, AGAF Michelle Baliss, DO Vinay Chandrasekhara, MD GI Pearls Turki AlAmri |تُرْكي عبدالله الْعَمريَّ MD Jahnvi Dhar Katarzyna Monika Pawlak Aziz Aadam Abhishek Agnihotri, MD Lauren Khanna Manol Jovani, MD MPH Prof John Leeds Zubin Sharma MD Srinivas Gaddam, MD, MPH Dennis Chen Violeta Popov, MD PhD Rashid Lui 雷諾信 Tyler Berzin MD, FASGE Ahmed Saeed, MD, DABOM Raj Shah Robert Bechara Antonio Mendoza Ladd MD, AGAF, FACG, FASGE Dennis Yang, MD, FACG,AGAF,FASGE Moamen Gabr 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)

#ScopingSundays Gowthami Ramar @EHolzwanger Mohammad Bilal, MD Ahmad Bazarbashi MD أحمد بازارباشي Carl Kay, MD Vaibhav Wadhwa Roberto Simons-Linares, MD Joseph Sleiman, MD, FACP Rashmi Advani, MD, ABOM Judy Trieu, MD, MPH Lizzie Aby, MD Ramzi Mulki, MD Kenneth Park, MD, MSc, DABOM Enad Dawod Natalie Cosgrove MD moiz ahmed Douglas G. Adler MD, FASGE, FACG, AGAF Abhishek Agnihotri, MD Anjum Gardezi MD Christina Tennyson MD Tom Tielleman, MD Sergio A. Sánchez-Luna, MD, DABOM (He/Him/His) Alex Perelman Mohamad El Zein MD, MPH  Mouhanna Abu Ghanimeh Shifa Umar, MD Ari Benson @lashagog Prof John Leeds #ScopingSunday #GITwitter