large colon polyps. We chose this topic because we think this is something that senior fellows can actually work on during their fellowship, right? Even if you don't want to do EOS, ERCP, bariatrics, and go on and do a third-tier fellowship, I think third-year fellows, particularly in the second half of the year, you can focus on this if you'd like. We've had third-year fellows in our program who, before going into practice, want to get more experience taking out large colon polyps so that they feel more comfortable when they get into practice taking these things out. So we'll go over some just basic techniques and things of that nature. But again, I think it's something that you can potentially focus on, a very satisfying procedure where you don't have to refer to another gastroenterologist or refer to a surgeon if you can take it out yourself. Again, my disclosure, Boston Scientific Consultants. So here are just some pictures of some difficult colon polyps for a variety of reasons, whether it be size, location. So we'll go through how to remove some of these. All right. So in terms of removing these things, first thing you want to do is assess the polyp. And then we can talk about removing it, okay? So the first thing, let's take a look, right? So look before you leap. So when it comes to assessing the polyp, there are things you want to look at, right? How big is it? What's the shape of the polyp? Where is it located in the colon? The orientation of the polyp, and then your scope stability. So it may look fairly easy, or you see a picture of it, say, from another endoscopy or another previous colonoscopy, it looks really easy. When you get there, you realize you're looped, you're in the cecum, your whole scope's in the patient. And so it can be difficult to actually maneuver your devices while you're in there, even though on the screen, it looks like it should be really straightforward, right? You also want to look for a polyp extension. So one thing you can consider doing is retroflexing the right colon. So here's a video of this polyp in forward view. Looks like it's already been tattooed there on the left side. And so a bunch of videos here throughout the course of this talk, feel free to ask questions throughout while you're watching the video, if you have questions about what we're doing, or why something was done. But here's retroflexing in the right colon to assess how large is this polyp, right? You saw the flat polyp, you saw it in the front forward view, you see how it extends over the fold, and majority of the polyp is actually on the backside. So as you just looked at this from forward view, you may not have actually realized how much polyp there was on the backside of this fold. So basically, we're going to do this polypectomy, this EMR in retroflexion, right? You want to lift the polyp up, and I think the methylene blue here nicely highlights the edges of this polyp, which is fairly flat. So now you can make out the borders of the polyp. I think I'll get to the resection later, all right? But the point being, you may want to look at the backside of the fold if possible, because polyps may extend over the fold. And then you want to look at the polyp morphology, right? The mucosal pit pattern of the polyp that you're looking at. And there are lots of classifications out there. I want to keep it simple. There's the Paris classification, and then there's this granular versus non-granular classification. So the Paris classification, it's broken down into protruded lesions, flat elevated lesions, and then flat lesions, right? So if you're a protruded lesion, you're a 1P, which is pedunculated, a 1SP, which is subpedunculated, and then 1S, which is a sessile polyp. The flat elevated lesions, you have a 2A, a 2B, and a 2C. You have these excavated lesions, which are obviously very concerning for not so much polyp anymore, but maybe a cancer. And you can have these combinations where you have a 2A plus C, for example, you have a flat elevation, which is this guy, plus a C, which is this one. So now you have a polyp that's flatly elevated here on the edges, and then central depression in the middle. Or you have, say, a 2A plus 1S, where you have flat elevation along the bottom, and then you have a sessile polyp in the middle portion of the polyp. So we'll go through some examples. So here's a polyp. You can barely make it out here on high-definition white light. On narrowband imaging, you can start to see the edges of the polyp here. With the injection of methylene blue, you can make it out a little better. But it's a pretty flat polyp there, right? So I'd consider this a 2B lesion, right? Very, very flat. I think of sessile lesions being at least the thickness of the snare. And you can see how this polyp is not going to be as thick as a snare, right? The question is, what percent of docs would miss this lesion? Probably a lot. I mean, and I'm fortunate in the sense that most of my patients have referred to me to have polyps removed. So if someone found this polyp, tattooed it, I'm assuming, it would be very hard to find this thing otherwise, right? All right, so here's another polyp. You kind of make out the fact that the edges look a little bit, they're flat. It's raised above this mucosal, the normal colon mucosa, but it's got a central depression there in the middle, right? So this would be more like a 2A plus C. And the last example is another polyp. This would be this combination 2A plus 1S, right? There's the flat elevation along maybe the back edge, and then this side here is a little bulkier than the rest of the polyp. The other classification is the lateral spreading tumors. So you have granular and non-granular polyps. So the granular ones, I think, are more common. These are the ones that look bumpier, right? These granules is what they're talking about, whereas the non-granular ones are very smooth. So this polyp extends over this fold and this fold, so this polyp extends over this fold and this fold, kind of like in between here, and then extends all the way around to here. So maybe at least a third, if not half, the circumference of the polyp, of the colon. But the mucosal pattern is smoother than this nodular pattern, this granular pattern. So why do we care about the Paris classification or this granular, non-granular classification? Well, it's because of the concern for submucosal invasion, right? So when you look at a polyp, you can only see the top, say, like the tree, right? But you don't have a sense of how deep it's going into the wall of the colon. And so these classifications can sometimes be helpful for determining or kind of assessing the risk that the polyp has now become potentially early malignancy, early cancer. So in a retrospective study looking at the different polyps based on Paris classification and looking at the percent that had submucosal invasion, you see that, maybe no surprise, this polyp here that had a central depression had a much higher rate of submucosal invasion, right? 32% of the time, this polyp with central depression had submucosal invasion. The other rates are fairly low. And then again, looking at granular versus non-granular polyps, the non-granular polyps have a much higher rates of submucosal invasion. So how does it affect what you do when you take these polyps out? I mean, I think in many cases, if the polyps are large, you're going to move them piecemeal. But on a granular polyp, they found that the largest risk, the highest risk of submucosal invasion is in the largest nodule or under the area that's depressed. And a non-granular polyp can be essentially either in the depressed area or can be multifocal, which is what makes it more difficult to assess. I mean, it has a higher risk of submucosal invasion because it can be invading anywhere throughout the polyp. So there's some thought that when you remove a polyp such as this, I mean, if you're going to remove it piecemeal, right, with a piecemeal EMR, assuming you're not doing an ESD where you're going to take it out in one piece, you may want to take out the area that has the highest risk of submucosal invasion first. So the area with the largest nodules, that'd be this nodule right here in the front. Take that off, right? So now it's been injected, it's been snared, take that part off, send it off to pathology in a separate bottle, and then take out the rest of the polyp, right? And if you get cancer in there, then you know you have a diagnosis of cancer, likely from that area that had the larger nodule. So it may affect your strategy for how you resect these polyps. All right, so once you've assessed the polyp, we talked about size, shape, location, orientation, scope stability, the extension, and now morphology. Let's go ahead and try to remove these things. All right, so before you get started, you have to have the equipment in the room, all right? So you'd have an electrosurgical generator, typically we use CO2 now for colonoscopies. You need some sort of injectate, you may want epinephrine depending on the bleeding risk, stiff snares, endoloops, hemoclips, coag graspers, amongst other things that we have prepared in the room, right? The last thing you want to do is have some sort of complication, and now you're looking for some device down the hall trying to find your coag grasper, hemoclips. So let's go through some of these polyps, all right? So let's talk about the pedunculated polyp. And I think for most patients, you guys have taken out pedunculated polyps at this point, most small pedunculated polyps, no big deal, right? What about the larger ones? So the technique is pretty straightforward, right? You put a snare around the base of the polyp, and then use coagulation to remove it. So here is a large pedunculated polyp, and you're going to see the stalk there. You see it's a fairly thick, long stalk, and I've got my snare worked around to the base of the polyp, right? Base of the stalk there, right? You see all this stalk coming at you, the polyp is now behind us. So here we go, and you use hot, hot snare. And what do you see? So you see the polyp is now behind us, and you're going to use coagulation to remove it. So here we go, and you use hot, hot snare, and what do you see? All right, so it's an arterial bleed in the center there. You see it squirting at us. All right, so that's the concern with these podunculated polyps, that there's a blood vessel running through the stalk of the polyp. That for small podunculated polyps, it's not much of a concern, but these larger ones, you get these potential bleeding complications. So there's a section associated with bleeding. There's an artery that runs through the stalk here, right? So imagine the blood vessel running through the submucosa, and then there's some blood vessel that's up there feeding the polyps. When you go to resect this thing, that blood vessel is at risk for basically spurting up at you. So it can cause immediate bleeding or delayed bleeding. So how to prevent it? So with some of these podunculated polyps, you may want to inject epinephrine as your injectate, right? Just not because you need to lift the polyp, it's podunculated, but just inject some epinephrine to vasoconstrict that artery in there to decrease your risk of bleeding. There's some suggestion of putting hemoclips on first, and then cutting over the hemoclips, but you've got to be careful not to snare the hemoclips, because otherwise you will just coagulate and send all the heat into the hemoclip, and you'll just heat up the clip without burning any of the mucosa, right? So you just get a really hot hemoclip, and you're not actually cutting through the stalk of the polyp. Another option is to use an endoloop, right? So this is a device, it's made of plastic. It's basically, it's like a snare, except it's much floppier. You want to familiarize yourself with how to use this device before you use it for the first time. But basically, it's a loop that you can place at the base of the stalk, and it basically chokes off the bottom of the stalk, right? Then you can use your snare to cut over the top of the endoloop. So I'll just fast forward here. So here's the endoloop. Here's the big polyp, here's the endoloop going over it. I'm going to wrap it around, find the base. I think I've injected this polyp with epinephrine. So when you deploy it, it kind of cinches as you deploy it, right? So you see that cinch device? So it's cinched on the end, and it's basically choking off the base of the stalk now, right? Think of it like putting a rubber band on the base of your finger and having your finger start turning purple, right? It's the same idea. And then you can take your snare, get over the polyp, onto the stalk. And typically, the whole point of having the endoloop is that you cut above it so the endoloop can continue holding down the stalk, holding down that artery that's sitting in the center of the stalk there. There you go. All right, so the loop is still sitting on the base of the stalk, but there wasn't any bleeding there, fortunately. Just another technique you can use to take out these large, pedunculated polyps. And then just to reinforce it, I put some hemoclips on to hopefully prevent delayed bleeding from the stalk there. There's the polyp. You can see that at the base of this, you know that you've got the nice negative margin because you can see the stalk there underneath the polyp. So any questions on pedunculated polyps? Just takes one of these to have a severe bleed for you to be very cautious in the future, okay? I had a couple of patients with pretty significant bleeding after a pedunculated polyp was removed, and it makes you really respect the stalk of these polyps. All right, let's move on to sessile polyps. So this is a basic EMAR technique. You guys have probably done this at this point, right? You inject underneath the polyp, raise it up, raise the submucosa, put a snare around it, and then remove it. So typically, you want to be in a short, straight position if you can with your colonoscope, and orient the polyp at 6 o'clock. This makes it easier for you to manipulate your snare. And then you want to use an injection agent because the polyp is flat, and so this is going to give you some buffer there to work with underneath the polyp. So use some sort of contrast agent. There are many things on the market now, but I typically use methylene blue and saline. If I'm worried about bleeding, say, in the stomach or the duodenum, I'll add some epinephrine in there. I use a dynamic injection, which I'll show you in the video. And then you try to inject the most inaccessible aspect of the polyp first, raise it up, and then go and proceed with either raising the rest of the polyp up or take that part off and then proceed with the rest of your resection. All right, so if it's under about 2 centimeters, you're going to try to remove it on block, right? We have 2-centimeter snares. Try to take it off in one piece. If it's larger than that, start at one edge of the lesion, develop a submucosal plane with the initial resection, and then use the edge of the mucosal defect to place your next there, and then you kind of move along. You don't want to leave islands or isthmuses of tissue in between your polypectomy. And at the end, you want to carefully evaluate the mucosal defect, make sure there's no perforations, look for any vessels that may be at risk for bleeding, and then manage any active bleeding complications. All right, so here's a sessile polyp. It looks like it's in the cecum. It's pretty large, right? This isn't going to be an on-block resection. As you can see, it's involving kind of the whole base of the cecum there. But you're going to lift it, just like you've probably done many times for smaller polyps, right? It's the same technique, same process. It's just iterative. You just do it over and over and over again, but you want to get to the point where you're comfortable doing this. Again, it's one of these things where our senior fellows, when they're in with one of us in the procedure room, when we're there, the fellows can do it. I don't know how many of these fellows will feel comfortable doing this on their own after they finish training. But some of our fellows, I mean, I still have fellows who send me pictures of their colon cells that they've removed, and they're in community practice, and they want to take these things out. I'm just working my way across the polyp, but see that the snare goes. I'm using the mucosal defect. I'm using the edge. I'm grabbing more tissue. I'm working my way across, right? I'm not jumping to the left side of the polyp, the right side of the polyp. I'm leaving tissue in between. I'm working my way from one side to the other side. More injection, just fast forward a little bit. So you guys can all do this, okay? I think the biggest thing you guys may think about is time, right? So if you have a full schedule of patients, scheduled for colonoscopies, you may not be able to do this in one setting, right? You may have to just document it and bring them back. If you don't feel comfortable taking it out, obviously you can refer it out to someone else to remove. But the technique here is very simple and straightforward. It just takes the time and effort to take it out. There you go. Okay, that's a sessile polyp. It's about flat polyps. So they can be difficult to capture within the snare, right, because they're so flat, you can't just take your snare and grab the tissue. So you can use technique where you use a distal attachment, and you see me using a distal attachment in some of these videos. It's just a cap on the end of the scope. And so very similar idea, you inject the polyp, but this time you can suck the polyp into your cap, and then close your snare. And there's actually an oblique cap that is on the market that has a snare kind of sits around the inside of the cap. So when you suck, you can close your snare just around the tissue that's in your cap, or you can just kind of make it work by sucking and then closing your snare on a tissue you have that's in the cap. So for example, the following. So you can see this very flat polyp here. You guys see that? It's pretty subtle. Again, you'll see it better once we inject this contrast agent underneath it. You can start to see the border there, this polyp, which is very flat. It's not even that polyp that I showed earlier. So you can see, if you just run the snare over it, you're not gonna grab any tissue, right? So I'm gonna grab what I can. And it's me just trying to grab tissue. Sometimes if you get lucky, if you have a nice lift, you might be able to grab the lift, the semi-cosa and the pot with it. Other times it'll just slide off. And I think this is just showing you how I just slipped off, right? I couldn't grab any tissue there. So I'm gonna try again. And this time I put the snare out. I'm gonna get my snare just outside my cap. And now I'm gonna suck the polyp into my cap and then have the tech close. The snare with the tissue that was in the cap. And I don't get a lot of tissue here, okay? But that's okay, because now I have the small mucosal defect that I can use to put my snare down, right? It gave me enough kind of an edge, a margin, where I can then put my snare down. And now when I go to do this next, same technique, suck, grab tissue, put my snare out, grab some more tissue, and I'm working my way across. I was able to grab a little more tissue there. But now I feel like I have some margin to work with, right? That defect, that edge I have works nicely. Put the snare there, suck again, grab tissue. And we have one more piece here on the right, I suppose. But there it is. And that's a very flat polyp that you would not otherwise be able to just snare off just using standard EMR techniques. And then there's some special situations. Usually, it's a location. So a peri-appendiceal polyp, one that's sitting in and around the appendix. So consider using an underwater technique. So now, the whole polyp underwater, you can see that the polyp's kind of extending out of the AO. Again, inject the most inaccessible area there. With underwater technique, you don't always have to inject either. You can just use the water to help lift it out. But in this case, I felt like I still needed to get some of that polyp out of the appendiceal orifice. You're going to have a cap, which kind of helps manipulate the polyp. I'm trying to lift that tissue out of the AO. If you inject next to it, you're just going to bury the polyp into the AO. You'll never get it out. So I'm working, again, in the most inaccessible area first. Stick the snare into the AO. Grab this tissue. Because you know the rest of the polyp is going to be easy and straightforward. I'm not worried about the rest of the polyp. It's just this first part that's right by the AO, that's the main issue, the main concern. But the whole thing is underwater. Everything's kind of floating. Throw some in there. This gives Claire use some forceps to grab tissue. I'm everting the appendix now, grabbing the tissue from the appendix and pulling it out so I can see the margin here. Now there are other advanced techniques to remove this, right? Now we have FTRD, it's a version of the Ovesco clip, the same company where you go in and you can basically bring this whole tissue into the cap, deploy an Ovesco clip underneath it, and then cut off the tissue over it, but the whole purpose of this lecture is to try to give you techniques that you can hopefully do with the techniques you have, right? The ability to use a snare and injection needle without having to learn FTRD, which I'd say a lot of people, a lot of general GI's are not gonna do an FTRD, set up the device and take out a polyp, right? I think that's the end. Do you use the tip of the snare to cauterize the bleeding? Yeah, of course. Yeah. So to treat bleeding, I use a snare tip soft coag. I also use it at the end of some piecemeal EMRs to burn the edges to ablate any residual polyp along the edge of the EMR site. So for bleeding and for ablation of tissue. All right, if you have an ileocecal valve polyp. So here's a polyp that's going to be sitting right on the IC valve. I think a cap here is very helpful. Because it kind of flattens the ileal tissue, exposes the polyp. It's based along the back edge there, at the proximal edge of the IC valve. And so in general, the IC valve and the rectum are two very safe places to do EMR. There's a lot of fat on the IC valve, so you can get away with a lot more there in terms of the resection. Sometimes you'll see some semicostal fat. That's not worrisome. And you can sometimes do these IC valve pops in their water as well. You see that polyp there along the edge. It's going to be hard to tell, right, because on the IC valve, it's right by the terminal ilium, the ileum mucosa, and villus adenoma look very similar. But again, I feel very comfortable taking a large margin here because it's the IC valve, right? Lesson from pediatric polyposis, fortunately not one that I learned myself, but beware the intersusceptive ileal polyp because sometimes there's ileum that comes with it. So I'm just working my way around the IC valve. But again, the point being here that a cap, I think, is very helpful in these scenarios. And the anorectal junction, right? If you get really close to the dentate line, it can cause a lot of pain, so just be conscious of that. They may need antibiotics or local anesthesia. But this polyp is down in the rectum, heading down towards the dentate line. Again, I think having a cap and a snare makes it much easier to remove these types of polyps. It's just an extensive polyp in the distal rectum. But again, the same basic EMR techniques. You may need to do some of this in retroflexion as well, just given the location. All right, so just when you approach a difficult colon polyp, this is you, right? You're scoping the patient, and many guys think I'm the greatest, right? I mean, you are the best endoscopist in the room, right? You're usually the only one. You look around like no one else is going to be there to help you, right? But your ego is not your amigo. So if you see a difficult colon polyp, you have a couple of choices, right? One is to completely resect the polyp. Two, leave it alone. Or three, refer to surgery if you really think it's cancer, okay? So I'm going to say no to surgery. Unless you think it's cancer, your choices are either resect it or leave it alone. Resect it all or leave it alone, okay? The point being, don't biopsy it if you think it's a polyp, right? I think most of you guys can tell based on the appearance if it's a polyp or not, right? If you're really worried about cancer, biopsy it, okay? I'm not telling you to leave a cancer in there and refer a cancer to another GI doctor to remove. But if it looks like a polyp, if it's large, just leave it in there. Just leave it alone. Don't biopsy it. Don't snare it. Don't remove half of it. Don't tattoo underneath it, okay? So all these things make it harder for the next gastroenterologist to remove the polyp, right? So you take a sessile polyp, and you inject it, you take out half the polyp, you take out 80% of the polyp, and you tell the patient, I took an 80%, don't worry, the next GI doctor just needs to take out the last 20%. Well, you left it very hard for us to remove, okay, because it gets scarred down from all the interventions. And we see this all the time where patients are doing this, and they're putting clips on at the end, and they're like, we couldn't take it all out, so now you need to take it out, right? And it makes it much harder for us if all these interventions are done to it. So we tell our general gastroenterologist, if you see a difficult polyp, you don't feel comfortable taking it out, just take some pictures, tattoo somewhere else, which I'll go into, and then leave it alone. Don't biopsy it. So tattooing principles, tattoo the opposite wall. That's a good thing. All right, so it's away from the polyp. Quite frankly, if it's a polyp this big, you probably don't need to tattoo it. Like, I think most of us can find this polyp, all right? Don't tattoo under the polyp. The other option is to tattoo several centimeters away from the polyp, right? Say you tattooed it distal or proximal to the polyp, let us know. There's no need to tattoo in the cecum. We know the cecum is. All right, so here's a polyp. Someone tattooed in the base of the cecum. Like, I can find this polyp if it's right next to the AO, all right? Like, this is the rectum and the cecum are the two places I can find. There's no need to tattoo the cecum. And there's no need to tattoo in the rectum either, all right? So this is an example. It's not even a large polyp, but this is a colleague who saw this polyp, injected it, and then thought it was too big, didn't realize how big it was when she first saw it, and then she decided to biopsy it. She didn't want to remove it. And not that it was hard to remove, but look how it looked like when I went to go take it out, right? It's not that big, but you can see there's a scar along the right side of this polyp from where that biopsy was done. Again, not a big deal in this case, but the point that you can see the scar tissue that was formed from that biopsy, which is why we encourage the general gastroenterologist to not touch the polyps. And it's taken some time, but they've come around now, and they often don't biopsy these lesions, right? Just take pictures, leave it alone, maybe tattoo it if it's somewhere difficult to find, and then leave it for us to take out. So either resect the polyp completely, or leave it alone, document it, and get out. But I basically took out the scar with the polyp. And this is just a minor thing, right, just a biopsy, but again, I've seen patients where they've snared and clipped and done a lot more interventions to make it difficult for us. So just some final conclusions. The PARIS classification can be used to assess the surface morphology of difficult colon polyps, preemptively manage possible bleeding complications when removing large pedunculated polyps, right, so injection of epinephrine and use an endoloop, things like that, to be preemptive, be prophylactic about removing these polyps before they start bleeding. Maintain the semicostal plane to remove sessile serrated adenomas in piecemeal fashion. The distal attachment is useful for removing flat polyps, I'd say also sacral polyps, IC valve polyps, you know, rectal polyps. And then do not biopsy, tattoo, or attempt resection of large or difficult polyps if not undergoing complete resection. That's it. Any questions? This session brought to you by ASG compression stockings. So how would you approach a patient with, like, large polyp which needs intervention and you are suspecting bleeding with inadequate bowel preparation? So should you cancel and you repeat later on, or you should proceed with resection? I'm sorry. Say that again? So if you have a patient, like, with large polyp, you need to, like, to do a hot snare resection or you need injection, and the patient had inadequate bowel preparation, so how would you do? Yeah. I mean, I think it's your judgment call, right? It depends. If you don't think, if it's going to be a long, if it's a large polyp, especially if it's flat and you're going to do a lot of, it's going to take half an hour to 45 minutes to remove that polyp, I mean, having inadequate bowel prep, you're going to be cleaning and washing for, you know, it's going to get annoying to do that during the procedure. It may ultimately get in the way of your EMR. And so I think the bowel prep's inadequate, you've got to bring them back, right? I think just practically speaking, if you come across these polyps, I'm not saying you have to stop, take the scope out, put a cap on, go back in, spend 30 minutes removing this polyp, and then come out and then be 30 minutes behind for the rest of your day, right? Practically speaking, you may see this, you may mark it, you may tattoo it, document it, and if you feel comfortable taking this out, then you bring it back another day, schedule enough time for you to take out this polyp on your own, or if you don't feel comfortable, refer it out for someone else to remove, right? But the idea being, these techniques are not that far advanced in the stuff that you guys are doing already, okay? You guys can biopsy, you guys can cold snare, you guys can hot snare, you guys can clip. This is just a little further along than that, but we have fellows in, you know, three of GI fellows who can certainly take out polyps like this without having to do an advanced cure, right? And as I think Dr. Faux mentioned earlier, it's a very rewarding procedure in the sense that you're preventing potentially a surgery for the patient, right? If you live in an area where they don't have an intramuscular gastroenterologist, you don't even get referred to surgery and patients get a partial colectomy for a large colon polyp that could potentially be removed endoscopically. So it's very satisfying in that way. I have a question from the chat. Can you comment a little bit about cold snare response there for EMR? Yeah. I mean, I think traditionally most of us have used hot snare for moving large polyps like this, Cecil polyps. There's been more and more literature now on cold snare polypectomy where you have a much lower risk of delayed bleeding, because a lot of the bleeding that occurs is going to occur right there in the procedure and you can manage it. So I think either is fine. It's whatever you're more comfortable with. But I think there's data now to support both hot snare or cold snare, depending on your technique, what you're comfortable with. I think many of us, you want to be able to do multiple different techniques because depending on the POP, you want to be able to kind of use the technique accordingly. But yeah, I think both are good options nowadays. I think a lot of it has to do with the technology, where we have better cold snares now to remove these polyps. We have better hot snares. The hot snares we use are stiff hot snares. These are not these floppy hot snares that you typically use for moving, say, smaller polyps in the colon. So again, I think as interventional gastroenterologists, we're fortunate because the polyps have already been identified. They're being referred to us. And so we are prepared to take these polyps out going into the procedure, already know in advance, get the methylene blue ready, get the stiff snare ready, pad the patient. I know we're going in to take out this polyp. As opposed to general gastroenterologist who's doing eight colonoscopies in the morning and come across this polyp, they're not necessarily prepared to take this thing out. The equipment, the staff, you know, it's understandable. All right. Thanks, guys. So I think we'll take a quick break. And then you guys will go into the bio lab for the hands-on session.

colon polyps

pedunculated polyps

sessile polyps

bleeding prevention

tissue capture

section removal

difficult polyps