So I will try to be quick, but I have a lot of stuff to tell you guys about. So I'm an advanced endoscopist, but if I were to do it again, not that I wouldn't do advanced endoscopy, but I love polypectomy. So just if you're thinking about, like, I like endoscopy, but I don't want to do advanced endoscopy necessarily, polypectomy is a great niche. There are probably groups that would love to have someone who does their big polyps, really. So I've had many fellows in their last six months of third year, we line up big polyps, we do them together, and they now go and do big polyps. So it's really fun, I really like it, and you know, you can save patients from surgery, so it's pretty cool. So I just also briefly want to talk about, I am on an ASG committee that is working on this compensation benchmarking. So you guys were all talking about MGMA and trying to get data. So this is something that we're rolling out soon, we'll definitely be at ACG. And basically, we are asking any gastroenterologist to put their information in, and this is like the whole thing. We want to know bonuses, compensation, VA, non-VA, private, you know, just to try and get, you know, how many hours people are working, just all the information that we can get, so that, and we're going to try and figure out how fellows can access it, because how we designed it was, if you put your data in, you could get data out, but if you didn't put data in, you don't get data out. So you guys obviously don't have data that we necessarily want, because you don't have a job yet. So we're going to try and figure that out, but what the idea would be is you're going to get a job, you can separate it by region, region of the country, private practice, academics, VA, non-VA, you know, whatever, you know, we have this big, huge database that hopefully we will have. We've really been working on it, and we finally think that we've figured it out, and it's not, it's actually, I'm chair of the Women's Committee, I almost wasn't going to say that. It's not a women thing. It's, you know, because men could look at it as, if women get paid less, men are going to get paid less. So this happened in pediatrics, in OBGYN, the salary ranges came down the more women that were there, because they were paying women less. So that's how I'm trying to sell it to men. So I'm going to get the men of ASGE to sell this, not just the women. So anyway, so just, you know, look to see this, and again, you know, you'll be able to get some data from this to help you look for jobs. So we will encourage all of our, all of our ASG and ACG and all gastroenterologists to put in their data. Okay, so on to my talk. So what makes polyps tricky? So polyps that are large, right? Polyps that are very flat, polyps that are in challenging positions, we'll talk a little bit about polyps that are scarred down, which is a large part of many people's practice, especially in advanced endoscopy, where someone's tried to resect it and it's scarred down, it's tattooed underneath it, things like that. So let's talk about some common pitfalls. So partial snare resection for tissue diagnosis. If you see a polyp, we are really good now at telling what's cancer, right? You can look at it with blue light, you can look at it with magnification, you're looking at the pit pattern, you're looking at the vascularity. So you can oftentimes, hopefully by the end of your fellowship, look at a polyp and tell me is it a sessile serrated adenoma, is it a granular, non-granular, you know, what's the nice classification, right? We have all these ways of looking at polyps, so we should be able to tell if it's cancer. If it doesn't look like cancer, you don't need to biopsy it to make a diagnosis for someone else to remove it, right? So you just can leave that alone. Certainly don't snare it. You can biopsy a bulky area, but you don't really, really need to. Don't tattoo the lesion itself, right? It's not a lifting agent. If you want to see if it lifts, that's fine. You can inject some, injectate in it that's, you know, saline, something a little bit blue, whatever, but don't inject tattoo under it. Again, don't attempt EMR if you don't think you can get it out, which is really important to inspect the lesion, right, before you start attempting resection. And, you know, we really shouldn't be sending benign lesions to surgery. The rates for surgery for benign polyps, surprisingly, are not decreasing, even though I feel like in the past 10 years, the toys that we have and the techniques and we're learning how to do ESD and full thickness, you know, you would think that we're not sending patients to surgery, but we still are. 25% of benign polyps in the U.S. are treated with laparoscopic colonic resection. And rate of surgery was highest among teaching hospitals. So it's a little strange, huh? And we know that there are complications. And if you've ever sent a patient to surgery who had a benign polyp and you look at the path in the end and you thought it was going to be cancer, it's benign, and then they have a leak and then, you know, then you feel really bad. So important basic techniques. So straight scope position is the number one. So if the fellows want to work with me in their third year, they have to be able to get to the cecum in 60 centimeters. So at our institution, we have intermediate scopes, which I know nobody else in the world has, or at least not in the U.S. Japan has them. But basically, you should be able to get to the cecum in 60 or 70 centimeters. And if you are not, if you are at the patek flexure, the splenic flexure at 60, you have a loop in, no matter what you think. Think about using a clear cap. I really love clear cap. It's a really cheap way for upper GI bleeds, but also in the colon, it really can push the folds away quite nicely. Again, you can inject a lifting agent if you are concerned that it could be something that's more advanced and it doesn't lift, then you can just call it a day. Consider your prep quality. Obviously, if the prep isn't great, if you think about, oh, I could cause a perforation, which is albeit very rare, but you want to consider prep quality so you can retrieve all the pieces of the polyp and then stools not getting in the way while you're resecting. And also figure out if you have time. I mean, if you are way behind already and you got a ton of patients, you don't want to feel rushed taking out this polyp because you just don't want to do a half-assed technique, half-assed job, and then have to bring them back and deal with all of that. So basic techniques, there's inject and snare, and we do a little bit of that in the pig lab today, and obviously can do hot or cold. There's underwater EMR. I'm going to show you a video of that, snare tip, anchor, avulsion technique I will show you, CAP, EMR, full thickness resection devices, and ESD, which is a little bit beyond the scope of this. So, again, you guys, I think, know the non-lifting sign. The way you want to inject, there's a number of techniques. You can start with having saline in the needle and start injecting as you go in so that as soon as you start seeing the lift, you know you've gotten in far enough. You want to, you know, hopefully have a tech who sees, and we were talking about this a little bit in hands-on because I was having the fellows tech, you know, if you see it spraying out, stop injecting. If you see it, you don't see any lift, you're probably too deep. So hopefully the tech is in tune with what you're doing. And then there's this mucosal blister. I'll show you pictures I actually got from one of Mike Bork's papers. So this is a nice picture of an intramucosal injection. See how bright blue it is? It doesn't really do a good job of lifting. But interestingly, you can see this if you have something that's tacked down and you try to do a submucosal injection and the submucosa is, you know, obliterated because of the polyp involving the submucosa, you'll get these blisters. So it can be a little bit of a hint. And you can actually make a little cut. He's showing making a cut here and the blister goes away. So that's kind of a clever technique. All right. So I am the worst at getting video. So I would tell you all if you're planning to do teaching to think about getting recordings. But I asked some friends for videos. And I actually asked Doug Rex for like unedited because I didn't want it to look too slick. So there might be a little, you know, because Doug's videos all look slick. So you're looking at this polyp, right? You've got the clear cap on. You're inspecting it. Some people like right here might be like, oh, you know, my fellows say this. There was a depression. Like is that really a depression, right? Probably not. So there's a little bit of this undulating. Just a quick pause here. What do you guys think of that polyp? How would you describe that? You guys have thoughts? That was a good picture right there. What does it look like? Granular or non-granular? But what about the, what about, hold on, that was a perfect, it's a mixed one, right? So you see an area that's smooth and then you see the area that is granular. So this is not a polyp that we would take off necessarily with cold. You could try. It's pretty bulky. The size isn't the issue, but it's a little bulky. It's also not, it's not, clearly not a sessile serrated adenoma, right? I'll talk a little bit about it. I forget I have, I don't have it in this talk, but you know, cold snare is a great technique and I love it and I've been using it a lot. But the residual, unless it's an SSA, is pretty high, up to 15%. Now residual adenoma is not like the end of the world. You can always go back and get it out later. But we know that for cold snare, for traditional adenomas, there is a high, higher recurrence rate regardless of techniques used, soft coag, things like that. So here you can see Doug taking out this polyp and you can see he does that sort of get the snare around it and then it's nice and tight, loosen it just a little bit, not a lot of it to get any potential muscle from coming out and then cutting through. And again, the cap is really nice in sort of inspecting the edges, inspecting the base as they talked about earlier. So I am not a fan at all of pediatric scopes. So you see how Doug had that snare around it and then he suctioned? So if you have a pediatric scope, you can't do that because with the snare down the channel, you really have no suction. You may have a little bit, but you don't have much. So I really like to use suction, especially to bring the lumen down. So just think about that. The other thing for women personally, I think, the caliber of the pediatric scope is small. So it makes my hands cramp. So if I use a pediatric scope, I really have trouble with that. So I am not a pediatric scope fan. It's very floppy. You're more likely to get loops. So I'm a big adult scope fan. So just, I think that demonstrates the difference. You know, like you'll hear one talk, you'll be like, okay, I'm only using pedscopes. And then you'll hear me be like, I'm only using intermediate scopes or adult scopes. So there's many ways to skin a cat and there's many ways to take out polyps. I mean, Doug does the right way, but anyway. So here you can see he's methodically going around and he's trying not to have any skip areas. So you want to try to avoid little islands. So you're putting your snare around and not leaving spots in the middle because that will just make your life difficult. All right. I'm going to fast forward a little bit here. This is the unedited version, which I asked for. Oh, I have a question. What do you guys think about what you're seeing there to the left? What do you see? That yellow stuff. Does anybody worry that that's, what are you worried about there? What's that? Or perforation, right? Is that like peritoneal fat? So I remember the first time I saw that, but this is actually the ileocecal valve and it's very fatty. So you can see fat there and you don't have to freak out, but just things to think about as you're resecting, right? But you normally see that sort of cotton candy looking submucosa that you like to see. And then you see that fat and you kind of get a little bit worried. And then there's clip closure. So this is, okay. This is a great example of hot avulsion, which is another technique that I personally love. It's sort of newer on the block a bit. Again, we were talking about hot forceps and it's a big no-no. I mean, nobody uses hot forceps for small polyps. I've reviewed cases of perforation with hot forceps. You know, you don't need to use it. There's no advantage to using it. There's only risk. But hot avulsion is a great technique where you're grabbing. It's a special setting and I'll show you the setting. I have a slide for that and you guys will have that in your slide deck to remove areas that are tacked down that you can't get a snare on. And then the soft tip coag around the edges. So hot avulsion. So again, adjunctive technique for when we do EMR. I use it a lot and I really think it works well. We know that resection is better than ablative. We used to think that we could just burn it, right? Just APC it or whatever. We know that we can't control the depth of that burn. So we can leave polyp behind and think that we did a great job. So we really want to resect any adenoma we see before we use any thermal therapy. But hot avulsion is a great technique where you're basically grasping the area that's flat that you can't get in the snare, you're tenting up, and then a quick touch on the yellow pedal. So you can see here there's no coag, right? And these are the settings that you would use. I think, okay, well, I guess Doug's video showed that technique. But that's a really great technique to use and you should learn how to use it. This is also the tip-in technique where you're basically make a little burn on the opposite side of where you want to snare and that allows you to sort of snug your snare in there and get around a polyp that you're finding challenging to remove. This is one of my colleagues had a scar from a rectal neuroendocrine tumor that had a positive margin which they pretty much all do and whether this is really necessary to do or not. But just something you can think about in the rectum anyway is band EMR after lifting. So he lifted it, band EMRed it, and you can see it looks lovely there. I would not try that in the right colon or anything. And then there's this full thickness resection device which is, it's basically like the Ovesco OvidSkip scope clip, same company. And basically they've added a snare to this so that you can go in for areas that are tacked down and use this device. A little challenging because it's a bulky thing to get it through to the right colon can be challenging. So patients who have a lot of diverticulosis and thicken, you know, muscular thickening or any strictures, you'll have a really hard time with this. I would say generally most average GI people don't really feel comfortable using this but basically you mark the site around the polyp, you're going to pull this into the cap, you'll be able to see your markings, you put the clip down, and then snare. So it's a pretty cool device, especially for polyps that are tacked down, probably from more likely from partial resection than from, I mean we're not advocating this for cancer. Patients with cancer need a cancer operation. But here you can see that's sort of the result in the end. And this is the device basically showing that you go down, you grasp the area, pull it into the cap, put the clip down, and then snare. So underwater EMR is also a very cool technique and this was sort of discovered or started really by Ken Binmuller who is a really smart guy who looked when he was doing EOS probe that when you had the lumen sort of decompressed because you know we fill the lumen with water when we're looking under EOS for acoustic coupling and he saw that the muscle area sort of rounded out and then the mucosa, submucosa sort of fluffed in the lumen. So his thought was like why not just try snare using underwater technique. So no injection required, you don't need to separate the tissue that you're trying to resect from the muscle layer. And so I have this nice video also from Doug. Yeah, distal rectum at the dentate line. So this is one at the dentate line that he decided this might be a good idea to use this. Remember rectal lesions, especially these big ones, are much more likely to harbor cancer than in the other areas of the colon. So you really want to look carefully. So here you can see he's just doing underwater, no injection. Getting the snare, you can see a nice little margin, he suctions a little bit, again the advantage of not having a pediatric scope. And then clearly you can see, and the nice thing with underwater is you really, things get magnified, right? So you can really see the edge. I've been doing a lot of polypectomy at the dentate line actually, I used to really be afraid of that. But, you know, if you think about what the surgeons do, I mean granted, you know, I test a little if the patient can feel it, right, you tighten the snare, like can you feel it? And if they say no, then I just hit the pedal real quick. So it's interesting, I've had patients that I APC in the rectum and they can feel it. I mean it's really bizarre, like deep in the rectum. So you never quite know. So I do a little tester. Injecting can hurt there even if the snare part wouldn't, so just be a little careful of that. This is another cool video that I got online. This is an appendiceal orifice polyp. So appendiceal orifice is a tricky location because, you know, you get sent these polyps and you're like, can I take it out, can I not? You're worried about it going into, you know, an area where you can't see. So this is actually a pretty cool video where you can see underwater and with NBI you can see, they'll show it I think a little bit better here, where you can sort of see, look at that. Isn't that cool? So here you can see this is normal AO and here's the edge of the polyp, right? So now under, using underwater, they're going to place the snare while underwater. So you can see the edge. Underwater is really cool. I mean, I don't know if you guys do water immersion to the cecum thing. I do that a lot. I really like that technique and I think patients tolerate endoscopy better. So you can see they're very carefully placing the snare. Now once you get blood, NBI gets challenging obviously, as does sometimes underwater, but it can really show a nice little resection margin and they're using near focus as well. So don't forget, like there are all these tools that we have, you know, that we can use when we're doing endoscopy. So there's NBI, there's near focus. The other technique is retroflexion. So I got this one from Raj Goswami. I'm telling you, I just asked all my friends for videos. So for those of you who played video games as a kid, you might be better at this than me. I'm very much like, wait, forward is back, back is forward, you know, it's hard. This is in retroflexion. You can see the scope here. So he has this polyp on the backside of the full, which you can imagine, I mean, he does have a clear cap. He might've been able to do it. Maybe he's just showing off. I don't know. So what kind of polyp is this, you guys? Little quiz. Yell it out. SSA. SSA, correct. So you can see it's sort of got that cloud-like, it's almost hard to see unless you put a little injection in, injectate in there. So these are perfect for cold snare. Residual rate of polyps with cold snare in these is like one, 2%, very low. And again, you can see he's pushing the snare into it, using a little bit of suction, and then you just go around and you cold snare, and then these cut really nicely. So retroflexion is probably best done with a pediatric scope, honestly. It can be hard to retroflex with an adult scope, so that is a limitation. But if you are using a pediatric scope, it might be easier. In the rectum, obviously, we retroflex there all the time with a regular scope, and that's where I get most of my experience with taking out polyps, which I know is why I'm directionally challenged with that technique. I don't know. You guys do retroflexion, polyp resection? It's a little hard. Doug, do you? Retroflexion? It's like... Phil? Yeah. Can you remember that forward is back and back is forward? I don't know. What's that? Small motions until you figure it out. Yeah. I mean, it's just, you know, you have to get used to the certain body motions and it's all backwards, so I'm challenged, obviously. So again, you can use an upper scope if you're on the left side of the colon. You can also think about that, right? You have a big polyp. You don't necessarily need a colonoscope. You could use a 1T scope if you want a shorter scope. You could use an upper scope, a little less flexibility. It's a very small channel. So things to think about. You know, you've got all these tools. You can use whatever works for you. So in conclusion, you know, pre- and post-EMR management is really essential to success. I personally, even patients who come from further away who've been referred to me, I just beg them to come back to me for at least the first one because you want to know, like, how well you're doing, right? I mean, otherwise, you're like, yeah, I rock that. And I find, like, times that I think that I was awesome and I'm, like, patting myself on the back. They come back and they have a recurrent, like, a big polyp and you're thinking, and then other times you just felt terrible about it and they come back and there's nothing there. So I don't know. I'm not sure what the answer is there. But I do like them to come back. I use a scope with water jet. I think most people have that, right? I actually thought everybody had CO2, so I'm a little bit shocked that people don't. Again, consider a retroflex position. I mean, I'm an academic, so we can have whatever we want, right? Consider a cap. Again, be really, you know, careful of, you know, how you inject and when you're injecting, what are you seeing? And have this toolbox ready. And if there are things that you've heard about or you like or you want to try, certainly try them on hands-on. I think we have a number of different devices for you to try. But really have this full armamentarian and watch videos online of how people do things because that's how you can come up with ideas and sort of learn, you know, ways to deal with things that are difficult.

polypectomy

endoscopy

non-invasive methods

ASGE compensation database

post-EMR follow-ups

advanced techniques