Host Raymond Cross, MD, brings in Dr Gursiman Kocchar to share his expertise in the management of strictures in Crohn's disease, from medical therapies to endoscopic procedures to surgery.

Raymond Cross, MD, is Medical Director, The Center for Inflammatory Bowel and Colorectal Diseases​, The Melissa L. Posner Institute for Digestive Health and Liver Disease at Mercy Medical Center​, in Baltimore, Maryland​. Gursiman Kocchar, MD, is System Medical Director of Inflammatory Bowel Disease for Northwell Health and Adjunct Assistant Professor, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell in Uniondale, New York.

Crohn’s Disease Strictures: Definition and Management

• Crohn’s disease intestinal stricture is defined as narrowing of the lumen. Radiologic criteria for a gastrointestinal stricture include >50% localized luminal narrowing, ≥25% increased bowel-wall thickness, and, when present, proximal dilation of 2.5–3 cm. Endoscopically, a stricture prevents passage of an adult colonoscope without prior dilation.

• Crohn’s strictures are usually mixed inflammatory/fibrotic lesions. On MR enterography the presence of edema, mucosal hyperenhancement, restricted diffusion, or comb sign suggests active inflammation; prestenotic dilation strongly predicts fibrosis. In STRIDENT, intensive adalimumab plus thiopurine improved 12-month outcomes, with complete imaging resolution in nearly 25%; CREOLE reported 64% success at week 24.

• Endoscopic therapy favors strictures <5 cm; stricturotomy suits 1–2 cm lesions (maximum 3 cm). Balloon dilation carries 2%–3% bleeding/perforation risk; target 15–18 mm and avoid dilation near large ulcers, fistulas, or abscesses.

Welcome everyone to IBD Drive Time, the official podcast of the AIBD Network. I'm delighted to have a returned guest, my friend Simran Kocchar from Northwell University Hospital, Northwell Health. And we're going to talk about management of strictures in Crohn's. Simran, welcome back to IBD Drive Time.

Dr Kocchar:

Thank you so much, Ray. It's a pleasure and an honor to join you guys back again.

Dr Cross:

So we're going to talk about Crohn's strictures, which can be a real challenge to manage. Why don't you start the list us off with defining how you define an intestinal stricture in Crohn's?

Dr Kocchar:

Sure. An intestinal stricture is generally defined as a narrowing of the lumen of the GI tract. It results from the combination of inflammatory cells and muscular hypertrophy, which results in fibrosis. There are various definitions. There's no one concrete definition. The radiology societies and Dr. Rieder's group has put together a radiological definition, which includes localized luminal narrowing. That is the diameter of the lumen is reduced more than 50%. There's bowel wall thickening, at least 25% increase in wall thickness. And if there is a prestenotic dilation, which is increased in luminal diameter proximal to the stricture by two and a half to three centimeters. From the endoscopist standpoint, it is basically inability to pass the adult colonoscope through a narrowed area that has not had a prior endoscopic dilation. We consider that as a stricture. So I think the definitions are more consensus-based, but these are the two most predominant ones that we use right now in our clinical practice.

Dr Cross:

And I just want to reiterate that it's an adult colonoscope now. So when you're using a peds colonoscope or an upper endoscope, you may be able to get through an area more easily, but usually you can tell that there's narrowing there when you're trying to traverse it. So I don't think we get too confused about that.

Dr Kocchar:

Right. I think if you have a peds colonoscope, actually, you may not be able to get through the area easily. You may have to exert pressure or push through it as we say. Then also you know it's a stricture. Upper, yes, you can get through an area easily, but you can see the narrowing that it is there.

Dr Cross:

So geez, my gosh, it feels like forever that I was in training—I guess it was forever ago—but the way we were taught, and I don't know if you were taught this way as well, is that there were two types of strictures. There's an inflammatory stricture and a fibrotic stricture. And how we determined that it was inflammatory is we gave prednisone and if they got better, it was inflammatory. If they didn't get better, it was fibrotic, we sent them to surgery. We know that that is completely flawed and that strictures are almost always mixed with inflammation and fibrosis. What can you as a clinician use to help determine if there's a significant enough inflammatory component for which medical therapy could be effective?

Dr Kocchar:

Yeah, I think that's a bane of our existence. Strictures are classified as many types, anastomotic versus de novo, inflammatory versus fibrotic, but the one that is most important clinically is does the stricture have inflammation? Again, no clear cut one single thing can tell us. However, there are certain tools that can help us identify. For example, most of my patients will have some form of abdominal imaging. If they have an MR enterography, there are features that can suggest active inflammation such as high T2 weighted signal intensity, which basically means there is a lot of edema there. If you see mucosal hyperenhancement in the arterial phase or there is restricted diffusion, or sometimes you see a lot of mesentric hypervascularity, which sometimes in the reports you may have seen as being referred as the comb sign. So these all suggest active inflammation. So this is where you might want to optimize the medical therapy.

The prominent fibrosis in the same MRE will actually have low T2 signal. There'll be delayed enhancement, and actually there's a delayed phases and gained enhancement in the arterial phase. And again, you should see some form of prestenotic dilation because from the fibrosis, the fluid tends to back up and cause dilation of the proximal segment. And those are the features which are suggestive of more fibrosis. CT scans are also helpful. On CT enterography, you may see mucosal enhancement, hypervascularity, fat stranding. These are all the words that you associate with inflammation. And now many centers employ into an ultrasound. And again, on the ultrasound, high vascularity is indicative of inflammation. But if you have absent or minimal vascularity, then that's indicated more of fibrosis, especially again, if there is a pre-synodic dilation. There are some other modalities in ultrasound. They're not as commonly used like contrast enhanced ultrasound or elastography, but that's based on imaging.

And on the endoscopy, basically you're going to see inflammation. If you go in and you see a lot of mucosal ulcerations, arrhythmia, friability, then you know this is a lot of inflammation in there. And a fibrotic stricture is usually. They still may have an ulcer, but that looks more like an ischemic ulcer, but they should not have friability, arrhythmia, granularity, or edema in the mucosal or submucosal space. But these are some of the signs that help us delineate. Because if we do suspect inflammation, and you are correct, most of our structures are definitely mixed. There is always a role to optimize and push for medications first before we decide on any other therapy.

Dr Cross:

Yeah, I agree. I think the one consistent finding across multiple studies is that prestenotic dilation is a sign of likely irreversible fibrosis. And when I see that, I downplay the effectiveness of medical therapy and refer to surgery if a patient's willing to do that. Bo Shen published an abstract, it's been over 10 years ago at DDW, that I still use in practice that talked about prestenotic dilation. If there's signs of obstruction on imaging, if you have associated abscess or fistula. And I think the fifth factor there was mesenteric stranding, which I don't think is a very good predictor of an irreversible stricture. And he found that if those factors are present, that basically all of those patients went to surgery. I don't know if you were an author on that abstract, but it never was published. But consistently across publications, I think prestenotic dilation is inarguable that there is an irreversible component of fibrosis.

Dr Kocchar:

Yes, I think I was not author on that abstract, but yes, I agree. Consistently we've seen that prestenotic dilation across multiple studies, both surgical literature and medical literature is actually a very strong predictor of fibrosis. Now in my clinical practice, I have seen fibrotic strictures and there may not be significant dilation yet. That's just a time effect. We just happen to pick up the stricture early enough before we give the bowels the time. So I don't want the audience to say if there is no dilation, it's not fibrotic. It just depends on the timing. But if there is prestenotic dilation, almost always there is a very strong fibrotic component, but there is always some inflammation component. In fact, I think in 2025 ACG guidelines, they basically said to optimize medical therapy even in strictures that have fibrosis, they played the role of anti-TNF. So I think the audience will not be faulted if they want to optimize medical therapy once they see a stricture, even if the component is more fibrotic than inflammatory.

Dr Cross:

That's a nice segue. So when you decide to treat these patients medically, what treatment do you pick? And I guess along those lines, what do we know about the effectiveness of our biologics and advanced therapies in patients with stricturing disease?

Dr Kocchar:

Yeah, I think the biologics definitely have played a role in stricturing disease. The strongest evidence of all the existing biologics actually comes from anti-TNF agents, especially adalimumab, which in high dose combination with immunomodulators has the strongest available evidence for us. So we have the STRIDENT trial. It was an RCT designed for stricturing disease in which patients receive high-dose adalimumab, 160 milligrams weekly times 4, and then 40 milligrams every 2 weeks, and combined with thiopurines versus standard dose of adalimumab monotherapy. And actually at 12 months, the intensive arm showed a superior obstructive symptom improvement, better radiographic stricture improvement, and lower treatment failure. And interestingly, complete stricture resolution also occurred on imaging in almost 25% of patients overall. So that study really put it out there, the role of anti-TNF. And then there was a subsequent multicenter prospective study, CREOLE study, in which 64% achieved success by week 24 being on medical therapy again treated with adalimumab.

When we look at the real-world data, again, we have a lot of data basically on anti-TNF from various studies showing a response to strictures. The newer biologics, we don't have as robust data for JAK inhibitors right now. IL-23 are still being studied in various cohorts of centers as to what it can do, but we don't have robust RCT level data like we have for anti-TNF. So I think medically, if a patient is bio-naive and they have a stricture, it makes sense to optimize their anti-TNF regimen, possibly consider a dual therapy along with immunomodulators, and also possibly dose intensification early on rather than later on. If they are already anti-TNF exposed or there are other biologics, then it becomes a little tricky because then there is not evidence to guide us, but basically we have to go by patient symptom, how much inflammation burden they have, and then optimize their medical management.

Dr Cross:

Yeah. There's also a paper by, I think it was Neeraj Narula, who looked at a number of different pivotal trials and looked at endoscopic response healing showing that there was a greater signal for anti-TNFs for ileal disease. I don't know if I prefer an anti-TNF for ileal disease. I think I prefer the agent the patient's willing to take. I think the one message though medically is …in STRIDENT and CREOLE, I always wondered if those numbers are a little bit more optimistic than what I see in clinical practice, but we could argue that all we want. But I think the one message for the listeners here is I think if you want to give your patient a trial of an advanced therapy for a stricture, that's fine. But this is the population where I don't think you should be cycling through multiple therapies.

I think with a stricture, I think a surgical reset is often needed. Try one drug. And I tell patients that upfront, "Listen, we're going to try one therapy.” I offer surgery upfront because we have LYR!C showing that even for nonstricturing disease, the outcomes are quite good. But oftentimes the thought of surgery for patients is foreign to them at that moment. So they want to try something medically, so I'll try something, but I don't typically cycle through a number of drugs. Do you agree with that?

Dr Kocchar:

Yes, absolutely. And I think there are certain factors that listeners can look out for. For example, if you have a nonpassable stricture on endoscopy, or if you have a predominantly fibrotic stricture from the features we discussed along with the presten dilation, if a patient has multiple strictures in a short segment or they have persistent stricture at 6 months despite optimized biologic therapy, those patients are not going to likely to respond to other agents. So completely agreed with you. Those are the patients that may benefit from endotherapy or surgery upfront versus cycling multiple agents and not being able to use them. So I think a lot of judgment call here on part of the physicians to see how much they feel the inflammation is there. But these few things can also help them guide, do they keep cycling the biologics or the patient needs a surgery or an endoscopic treatment?

Dr Cross:

And for patients that have had prior surgeries with anastomotic strictures, do you treat them differently from de novo strictures?

Dr Kocchar:

Yes, that's a great question. So anastomotic strictures actually differ from de novo stricture in the pathophysiology and how they are found because anastomotic strictures tend to be more fibrotic. They are driven not just by the Crohn's inflammation, but they're also driven by the surgical and technical factors. And sometimes when you have a stricture just at the anastomosis, it has more to do with the surgical and technical reasons than Crohn's disease per se. So those strictures likely will not respond to medical therapy. They will respond to endotherapy or surgery based on how long they are and how severe they are. So medical therapy definitely is less effective for anastomotic stricture. Just if you look at the other side, the de novo strictures or primary strictures, they don't respond very well to endoscopic therapy. So they are the ones that are actually, we should be pushing for medications and if not, possibly going the surgical route.

In fact, there was a paper by Cleveland Clinic Group long time ago, I want to say probably 2014, 2015, I think Dr. Ashisha Atreja led that, in which they showed that de novo strictures don't respond well to endoscopic management, but they respond much better to medical and surgical management.

Dr Cross:

So before I ask Simran a few more questions, just want to remind the listeners that IBD Drive Time is sponsored by the AIBD Network. There is a nurse practitioner and physician assistant meeting sponsored by AIBD coming up in New York City, October 17th to October 18th. So for the APPs out there in the audience, that's an excellent meeting to attend.

Simran, let's talk a little bit about endoscopic treatment. We can do balloon dilations. Some providers like you can do stricturotomies. There's been some studies looking at stents. So two-part question, which usually stink, but I'm going to ask you a two-part question. Which technique is better? Or maybe which technique shouldn't you do? And then who is your ideal candidate for endoscopic management of a stricture?

Dr Kocchar:

I think that's a perfect question. I think we can summarize it as follows. So whenever I get a patient with stricture, we look at the length of the stricture. How severe is the prestenotic dilation of the stricture? And are there any fistulas or abscesses in the visceral stricture? So if your stricture is longer than 4 to 5 centimeters, they are less likely to respond to endotherapy. If they're less than 5 centimeters, then you can choose balloon dilation, stricturotomy, even some rare cases stenting, although we'll talk more about stenting in a second, but modalities, the 2 main are balloon dilation and stricturotomy. Stricturotomy per se works very well for short fibrotic stricture, 1 to 2 centimeter, maximum 3 centimeters. Anything longer than 2 to 3 centimeters, balloon dilation will do just as good of a job, but great job compared to stricturotomy because as the stricture gets longer, the incision therapy becomes less effective.

So my choice of the procedure usually depends initially on the length of the strictures. Then there are some technical factors when you go in, some strictures are more ulcerated than the others. So sometimes using balloon broadly is a little bit challenging. So that's the time when sometimes you can selectively cut the scar tissue with the knife. But that usually is not the case in anastomotic strictures or fibrotic strictures.

Now a word about stenting. So enteral stenting always has been an avenue of interest. I still feel there's a lot of potential in that field. There was a study from Europe, multicenter RCT PRODILATE study in which they had 51 patients in the balloon group and 49 in the stent group. And balloon came out to be superior than stent at the end of one year, both in patient symptom management and also was more cost-effective. I think that study's very well conducted. It's an RCT, very good level of evidence. But one word of caution here is that we do not currently have stents that are made solely for purpose of benign disease in small intestine and colon. We basically repurposed esophageal stents, which are leaner stents, come in fix edsizes, and then we repurpose them to be deployed in TI and other areas. So I think till we have good stents designed for small bowel and colonic disease, I think writing of stents might be too premature. I think this field may see a lot of potential in next 5 to 8 years as our techniques evolve and we get better stents in market. But till that time right now, the two major modalities for endoscopy are balloon and knife therapy, and that we decide based on the length of the stricture.

Dr Cross:

Yeah, most of the listeners I think are going to be doing balloon dilation and we're going to get back to some tips on the best practices for that. But I want to make sure you agree with this statement is when I talk to patients, first of all, I consent to every Crohn's patient for a balloon dilation before the procedure because you may find a stricture that you weren't suspecting and to see above that area to see if there's inflammation, to address current symptoms, to potentially prevent obstruction. I personally will dilate a stricture like that, but I think if you haven't told them that there's a 2 to 3% risk of bleeding or perforation, which are the standard complication rates of balloon dilation, you really shouldn't do it. But what I was going to say is that I usually quote them that there's a rule of thirds. A third of patients do great with a single balloon dilation. A third of patients need multiple dilations to stay open, and then a third it doesn't work at all. So for that latter statement, do you generally agree that that's the efficacy of balloon dilation?

Dr Kocchar:

Absolutely. I think that's a very good statement to give. And I have a same practice like yours. I almost always, even if I'm doing a routine procedure for follow-up at 2 years, I will consent them for balloon dilation just in case if we see something. Because we have now good evidence to say that patients with Crohn's disease can have very poor symptom correlation. So sometimes they may have a stricture in TI and they may not be having any symptoms. So I think it's important to do that. But the numbers you gave, they are exactly the same numbers that I discuss with my patients in the clinic.

Dr Cross:

So what are the best tips for the endoscopists out there if you're going to do balloon dilation? Give them several tips for best practices.

Dr Kocchar:

Absolutely. I think once you see a stricture, I mean, ideal case scenario is that your patients have had some form of imaging in last 2 to 3 months whereby you know there is a stricture, but sometimes that's not possible. So if you do encounter a stricture, the safest way to dilate a stricture is what we call as a retrograde dilation, meaning in which we are able to pass the scope through the stricture and on our way back we dilate after we have examined that. Many times that's not possible. So I recommend using a wire-guided balloon whereby you can pass the wire first, then the balloon on top of it, inflate a balloon to size. There's a lot of judgment call in this. If you have an adult colonoscope, you have to decide what size to start based on how the lumen appears to you. So that's a bit of a judgment call there.

But one thing I do recommend is that when you do dilate, you dilate to a size, I almost always take the balloon back down, examine the mucosa, then redilate up to next size. I don't solely rely on the amount of resistance my tech is feeling when they're dilating up. And I also try to visualize through the lumen of the balloon when they're dilating, but even sometimes in that you can't pick up some tears. And in IBD patient, perforation or tears can happen irrespective of the size of the balloon, which basically means that you may be dilating up to 10 millimeter, even that can cause a perforation. You don't necessarily have to be at higher sizes. So if let's say you're dilating someone from 12 to 15, dilate them to 12, get good 30, 40 second dilation, take the balloon down, examine the area, go back to next size 13 and a half. Again, keep it there 40, 45 seconds, balloon down, then take it back to next size. So I think that is the safest way of doing it.

There is no real indication right now to inject steroids. When you dilate in IBD patients, we think they don't work. We did recommend this in one of the global consensus guidelines for stricture as well, which Ray, you were part of as well. So we did recommend that time not to do this. The target size that I target is about 18 millimeters, especially in colon and anywhere from 15 to 18 in small intestine as well. But ideally, if you can reach up to 18, I think that is an ideal site. Now, sometimes it's not possible, so you can dilate them to 12, 13 and a half, 15. Anything less than 15, please bring them back in 3 to 6 months and redilate and take up to a larger size. Because if we send them out and call them back in 1 to 2 years, whatever dilation you did pretty much negates its effect because stricture goes back to original size. So that is there.

Now, if there are large ulcers or there is a fistula in the vicinity, I would recommend not doing balloon dilation at that time because then you can make that fistula or abscess worse. Ulcers, we do not know how much tensile strength they have to take the radial force of the balloon. So even in those cases, I think one should not try this. And interesting enough, since we're on topic of the balloon dilation, there is currently a clinical trial going on of using drug-coated balloons. I don't know how that will span out, but that is something to keep in mind in future. But in those balloons, also same principles apply as we apply with these balloons as to be cautious after each size.

But don't be afraid to dilate. I always tell all my fellows, I hope some fellows are listening, that is one skillset you should be able to master in your 3 years of fellowship because it is a very good procedure still that is very effective for the patients.

Dr Cross:

I just want to summarize, and I agree with everything that Simran said. So short strictures, less than 5 centimeters. Anastomotic better than de novo, although you can certainly try with a de novo stricture. You want to make sure it's a straight stricture where you can see sort of through the balloon and no role for steroids, and size absolutely matters. So there's been studies showing that getting at least a 15, but my goal is exactly what Simran said is 18 millimeters. And sometimes you have to bring patients back, whether you bring them back in a month like I do, or 3 months or 6 months, but you need to bring them back and try to get the balloon up to 18 millimeters.

One other point that I think is really important, and Simran, you mentioned this, is the technician in the room is incredibly important. And the pressure they feel when they're getting that balloon up is really important. And I ask them, how much resistance did you get? Do you feel like you could go one grade higher? And if the technician says it felt like I was pushing against the wall, I stop. That's my last dilation. Even if I went 12, 13 and a half, plan to go to 15, if they tell me they could barely get the balloon up to 13 and a half, I stop. And then what I'll do, I typically hold the balloon for 30 seconds. And then as they're putting the balloon down, if I haven't been able to go retrograde, if I'm going antegrade, I'll sort of follow them through with the balloon. And it almost acts like a savary dilation as you go through with the balloon and it makes it much more likely you're going to be able to traverse the stricture. So I don't know if you do that, Simran, but I try to follow the balloon in as they're deflating so I can get through the stricture.

Dr Kocchar:

No, absolutely. Yes, that's exactly what I also do is as they're deflating the balloon, that's the best time to squeeze through. And that's an excellent point actually. And I think it just goes back to one more thing. When fellows are in training, they should be able to play the role of a tech on one or two dilations to exactly feel that tension or the resistance you and I are talking about. I think I did that. I was fortunate that my mentors asked me to do that because sometimes if you have a new tech in the room or not an experienced tech, it's just easier to feel the gun in your own hands and feel how much strength is there.

One additional thing we didn't talk about, and it's something I get asked often, is should we use fluoroscopy or not? I think it's a very individual call when you're dilating to use fluoroscopy or not. If you think it's going to help you to see, visualize the wire, go under x-ray guidance, sure. And in that case, if you're using a balloon, then I recommend using half and half contrast. And in that case, the way to tell if you have achieved adequate dilation is that the waist of the balloon should straighten out in the stricture in the middle. If that straightens out on the fluoroscopy, then you're good. I don't use fluoroscopy for routine dilations in my practice. But again, if you're starting out early, you feel that it's going to help you manage and take care of patients safely, please feel free to use it.

Dr Cross:

I agree. I don't use fluoroscopy and I don't actually use a guidewire either. You mentioned the paclitaxel-coated balloons. Yes. I actually think we were a site for the trial, and I actually think those balloons are going to be effective. I think they're going to be shown in the trial to be helpful.

What other novel therapeutics might be coming down the pipeline for stricture management?

Dr Kocchar:

I think drug-coated balloon is definitely the one. I'm also part of that trial. We are hoping that it yields good results because that will definitely add avenue to our patients. Again, I think enteral stenting is a space that I'm keenly watching. I think that will probably, we might have in the future. There is some discussion of testing our lumen-apposing metal stents, although LAMs are currently not FDA-approved for intralumenal use, but there is a thought process should those be used for short fiber optic strictures. There is, again, a push to look for biodegradable stents for IBD disease. That is also an avenue that is there. There was a case report I think Dr. Shen had published, noard published, but there's also some renewed interest of should we use EndoFlip? It's a endoluminal functional imaging probe that was actually used in management of patients with achalasia who undergo POEM procedure to see how much exact strength they had before myotomy and after myotomy.

So I think EndoFlip can be an option. It's just a little difficult to advance it to the stricture locations that we currently experience. But something to keep in mind that in future, if our tech gets better, those techniques might be incorporated for us to do. I still think there's a role for endoscopic stricturotomy to expand. Our knives are getting better. The length of the knives is getting better. So I think that is also an area that will keep continuing to expand for us to do probably longer strictures in future for strictureplasties.

Dr Cross:

And then we have the antifibrotic systemic therapy that Flo presented at, I think it was at DDW. It was more showing about safety, but looks promising. And I think the anti-TL1As are billed as having an antifibrotic component. They're not going to be approved based on that, but it'll be interesting once those drugs get to market to see if patients with stricturing disease perhaps do better with that mechanism of action. I don't really have a guess as to how that's going to play out, but we do have even some medical therapies that might be available for our patients.

So Simran, you're a return guest, so I'm not going to ask you a fun question, but I'm going to ask you a different question. If you weren't a gastroenterologist, what would you be? So if you weren't a doctor, what do you think you would be?

Dr Kocchar:

I don't know the answer to that, honestly, because back when I was growing up, premed school, the only option was to be a doctor. Remember, I'm from India and my mom is Indian, so there were not many options. You have to be a doctor. But now if you ask me what would I choose, I think I'll probably choose one of the two careers. These two are kind of my passion. One is I love to eat out at very good restaurants, so I probably would've been a chef who would've gone on a journey to explore and discover all these lost recipes that we have lost over centuries. I think our ancestors made some really good food, so that is definitely a passion.

And the second passion is aviation. I love planes. I love those machines. I think it's fascinating every time I sit in a plane. And now I do fly planes in plane simulators. In fact, there is one close to your house in Maryland that you can go and fly in a Boeing 737 simulator. It's actually fun to do that. And hopefully if my wife allows, I'll have my own home simulator one day to fly planes. So those are my current two areas which I'm very fascinated about.

Dr Cross:

And speaking of cooking, when I went to the Allegheny Health Network course, Simran invited me to his house and his wife and his mother made dinner and it was phenomenal. So lots of good cooking genes in family and married into good cooking genes. Simran, this has been great. For the listeners, remember we're on Apple Podcasts and Spotify and IBD Drive Time is the official podcast of the AIBD Network. Simran, thank you.

Dr Kocchar:

Thank you, Ray. Thank you so much.