So, this is a little bit of a less exciting talk, but I think it's really critical, especially as you embark upon an advanced lesion resection practice. These are my disclosures. We're going to talk about the consent process for doing complex polypectomy, talk about the importance of a good bowel prep, we'll talk about some of the complications, and this will be just kind of a brief overview of them because there's a talk later on today that's going to get more into that, management of this, and then also best practices for surveillance intervals. So when you're getting ready to deal with a case that's maybe been referred or that you've found on a colonoscopy, in advance of that case, it's very important to review the patient's medical history. So in our practice, we have a large referral practice for open access advanced endoscopy. And so we get a couple hundred referrals every year for, you know, large polyps that need to be resected. And those are all reviewed by one of the six therapeutic endoscopists. We sort of make sure that we have a system in place with nurse coordinators who retrieve all of the pertinent information about the patient. So we have an assessment of, you know, what their comorbidities are, what they're like. We have the procedure report from the referring physician. And another key critical piece is looking at the color images, right? So if they fax over a report and it's all in black and white, we're trying to really disposition how much time we need for this and who's going to do it and what techniques are going to be used. We really need color images. And so those are some of the things that you're going to, you know, you want to look at. Look at the size, location, the number of lesions that are there. It's also really important just before you get started to look at where the tattoo is. Because if they're tattooing somewhat appropriately, if it's a difficult to see lesion, you know, you want to see where that tattoo is so that when you find the tattoo, you can then coordinate where you think the polyp's going to be if it's difficult to see. It's important to, you know, note if there have been previous attempts at removal. Because as we discussed yesterday, some of these are going to be fixed and fibrotic. They may be a little bit more challenging to remove. And so you need to be prepared with those things to kind of have a plan of attack in case it is adherent. It's also important to assess how much time you'll need to do this. And that a lot of times depends, you know, on the person doing the procedure, the location of the procedure, how easy it is to, the location of the polyp, how easy it is to get there. And then your technique, right? So an ESD is going to take, in most cases, is going to take longer than an EMR. And so, and also the size, right? So a lot of times, you know, a very large, difficult location polyp might not be able to be accomplished within a typical 60 minute timeframe. So in our institution, we are sort of baseline EMR as a 60 minute time slot, whereas for a screening colon, it's a 40 minute time slot. So you have a little bit more time. And then you also have a team of people who know, you know, what they're doing. And then it's also to plan in advance what kind of tools you're planning to use, right? So if you're, if you look at the lesion and you decide, well, I'm going to embark upon underwater EMR, you need to have, you need to be prepared for that and you need to communicate with your team so that they know, they know what tools you'll need and what kind of resources you'll have available. It's also important to notice in the prior reports, if the bowel prep was suboptimal on the initial exam at the outside place, because you might want to give them an extended bowel prep or some additional education on how they can achieve a better bowel prep. The next thing we'll talk about is informed consent. And this is really an opportunity. It's a step in our process. We do it for every patient. It's pretty routine, but it's really important to do a solid informed consent. And this, especially if you're doing open access endoscopy, I mean, how many of you are doing open access endoscopy, right? So a lot of you, you know, no matter what you're doing, you're meeting these people for the first time and it's your chance to learn about the patient and the patient learns about you. And it's a chance for you to gain their trust that you're going to do a great job, that you're capable and you're going to do a great job at treating this lesion and that they're in expert hands. Right? So that's, that's what your task is in part when you're, when you're giving an informed consent, it also allows you to establish a rapport with the patient and then discuss what you plan to do. So I always, I try to show, you know, the patient's pictures of what we're, what we're looking at, what we're going to remove, how we're going to do it. And then the intra-procedural, post-procedural complications. It's important to discuss those and also how you'd handle those, right? Well, what if bleeding happens? Well, what if bleeding happens? What are we going to do? So you know, I talked to them about what, what tools I have and what my plan would be as well as, you know, the, the delayed bleeding and how those things are handled. And sometimes when I say, you know, you have a risk of delayed bleeding, well, what happens if that happens? Well, you have to come to the ER or, you know, because you're not managing a post-polypectomy bleed at home generally, you know? And so a lot of times they, they didn't know that that's what would be required. And and so it's important to discuss these things. Some people are like, yeah, I'm going to Tahiti in two days. It's like, well, I don't know if like removing this five centimeter, you know, polyp is the best, you know, is the best timing, right? So those are things that you should definitely discuss. It's also important to not only have this conversation, but to document it. And any specific issues that you discussed, you want to have on the consent form. And then you also want to tell patients about the anticipated subsequent surveillance. This is not a one and done thing. If we take off a large, you know, polyp in piecemeal fashion, it's not, you know, sayonara from here on out, you're going to be following them fairly closely, which we'll get into. This, the ASG standards of practice committee actually published a guideline earlier this year on informed consent for GI endoscopic procedures. And this is, you know, really the basics of what you should be doing. And I'm, I know that many of you know this, but I think it's good to review so that you're at least covering all these basics, because if you do this each and every time, if something were to happen and things were to go awry and you find yourself in a medical legal case, you know, that these are the things that I always do, you know? And so, these are important components that have to be done every time. And so, it's also important to let them know if you plan to use non-FDA approved or off-label techniques and devices. It's important to document that in the consent. That's something that is frequently, I think, you know, we don't always pay attention to that. And so, if you're, you know, for any type of procedure, anything off-label, you want to specifically put in the consent. Key components, like I said, review the patient's medical conditions and pertinent results, right? Do they have a low platelet count? You know, are they anti-coagulated? You know, all those types of things. You know, have a description of the procedure, including the anticipated therapeutic things, the reason why you're doing this, right? So, you want to tell them why we're taking this off, why it's important to remove this lesion. And also, the potential risks and adverse events. It's important to tell them, to kind of give them an estimate of the frequency and severity of the most common and most severe AEs. It's also important to give them alternatives, right? Yes, you're here, you're prepped, this is the first time I'm meeting you. But if this doesn't sound right to you, you know, we can delay the procedure or we could, you know, discuss some of the options. But it's also key to tell them the potential harms of doing that, right? So, if we delay indefinitely, this may happen. If we delayed by a month for you to think about this, then, you know, less of an issue. Also, if, you know, if intra-procedurally things were to go awry, and anesthesia, if you're working with anesthesia, they do a good job at this, discuss the potential need for intubation, resuscitation, hospitalization, and blood transfusion. And then, of course, all of this should be documented. So my typical informed consent for EMR, so I personally don't do ESD. But for bleeding with EMR, I generally quote that as a 5% to 10% risk of delayed bleeding. And then less than 1% for EMR, maybe a little bit higher for ESD. There's also post-polypectomy syndrome, which really, if you're doing cold EMR, is not an issue. You may also, you know, not be able to completely resect the lesion. So that's a risk of, you know, you undergo this procedure, but it was not successful. It's important to tell them that, or incomplete resection. And then with any colonoscopy, I always, you know, consent for the possibility of missed lesions, not just in colon cancer screening exams. You know, if you have a procedure, they found a large polyp, they seemingly took everything off at the prior exam, there's oftentimes actually a pretty good likelihood that there will be additional small lesions that were missed, and that you may also miss them. And then, of course, cardiopulmonary events associated with sedation. As I mentioned, why is this procedure being recommended? You know, we want to remove these while they're still benign and non-invasive, and it's the least invasive way to decrease the risk of developing colon cancer. And then the alternatives to colonoscopy with resection are surgical resection or colonoscopic surveillance without resection. Just a few words now, shifting gears to bowel prep quality. This is really important because we know that the diagnostic accuracy and the therapeutic safety of colonoscopy with or without maneuvers in part depends on the quality of the bowel prep. And having a suboptimal bowel prep or an inadequate bowel prep can cause failed detection of neoplastic lesions, not only the ones that you're going after, but as I mentioned, other ones. But it also, you know, a suboptimal prep causes prolonged procedural times, the potential for repeated examinations if you really can't accomplish what you need to do, earlier intervals and increased complications. And it's, like I said, increased risk of procedural adverse events. And you can imagine this. Of all the videos that you've seen, you know, yesterday and for the photos that you've seen, how many of them had a suboptimal bowel prep? Zero, right? They all were done with a good bowel prep. And it's really important, especially when we're talking about characterizing the lesion, you know, your Paris classification, your NICE classification, all of those things are done in the setting of a good quality bowel prep. If there is debris and stool around it, you really can't get an adequate assessment of it. And that's really important. The other thing is that if there's a lot of stool in the colon and you're resecting things, you might have a harder time seeing the margins to make sure that you've achieved an adequate and a complete resection. And unfortunately, if complications were to occur, such as a full thickness perforation, you now have the potential for fecal soilage, which can increase their risk of complications. We know that bowel prep quality significantly affects adenoma detection rate and advanced adenoma detection rate. And so in terms of colonoscopy quality in general, it's very important to have a high quality bowel prep. And your center should really aim to have, you know, ideally greater than 95% high quality bowel prep or an adequate bowel prep. And you should also at your center adopt, if you can, a standardized way of reporting the quality of the bowel prep. So these are built into many endoscopic software programs. And some people use the Boston bowel prep. Some people, you know, use adequate, you know, good, excellent, adequate to detect lesions greater than five millimeters. But whatever your system is, you should stick with it so that you can follow your metrics over time. Like I said, it helps visualize the size and shape of the polyp. It's important for polyp characterization. And very importantly, it can help you assess the adequacy of the resection. So going into complications. So bleeding, I think, is the most common adverse event related to EMR and polypectomy. There's rates between, you know, 10 and a little over 20% after EMR colon lesions that are greater than 20 millimeters. And some of the factors that predict this are lesion size. So the larger lesions are at higher risk. So EMRs 2A and 1S, polyps with either tubulo villus or villus histology. And then also these EMRs being performed at low volume centers are also risk factors. Snare tip soft coagulation for treating the subucosal vessels within the bed of the resection has been shown to be safe. And we'll talk a little bit more about how effective it is. Monopolar hemostatic forceps and clips may also be effective. But despite this, the delayed bleeding rates after colon EMR range from anywhere from 2% to 11%. And about a third of these generally will require endoscopic therapy. So what to do if somebody comes in with a post-polypectomy bleed? Well, our practice is, you know, they come in and if they're having significant, you know, hematochezia, maroon stool, assess their hemodynamics. And if they're hemodynamically stable, we will follow them and give them a bowel prep. And if they continue to bleed through the bowel prep, then that's usually our indication that this is continuing to bleed and will require endoscopic therapy. If they do the bowel prep and things clear, then we continue to monitor them. And oftentimes, no intervention is needed. But about a third of the time, we'll have to apply endoscopic therapy, which means that probably half of the time, we're going in to do a colonoscopy. Risk factors for delayed bleeding are proximal colon location, the size of the polyp. And if you had intraprocedural bleeding, that also predicts that there may be a higher risk for delayed bleeding. This is a study that was published several years ago on prophylactic endoscopic coagulation using hemostatic forceps to prevent bleeding after wide-field EMR. And this was a randomized controlled trial. So we don't frequently see that in endoscopy. So I thought it was important to point this out. It was almost 350 patients undergoing wide-field EMR. They were randomized one-to-one for preventative endoscopic coagulation with the forceps versus no additional treatment. And the clinically significant post-endoscopic bleeding occurred in about 5% of the group that was treated versus 8% in the controls. And this was not statistically significant. But they did find that clinically significant bleeding was associated with a proximal colon location. What about perforation? So luckily, it's rare, probably closer to 1%, but it can be serious. It's very important to carefully inspect the resection defect and the resected specimen for the target sign. So we all know about looking at the defect, but then also looking at the polyp that you've removed and the underside of it to see if you can see that target sign. Hopefully you can't. It makes it easier to do this when you've used a contrast agent in your injectate, like a blue. Small perforations can be closed with clips, and that can also be used in cases where you see muscle. So the muscle is going to be very linear, very organized, straight white fibers. And so if you're resecting deep into the MP, you may also want to place clips, because you know that if you've used cautery, that additional injury may occur in the subsequent hours to day. Endoscopic suturing may be warranted. That is potentially problematic, right? Because our full thickness suturing device fits on a gastroscope, and you may be in an area in the colon that you cannot reach there with a gastroscope. So that's something to consider. There's also, through the scope, a suturing device, which is more of a mucosal close, and that may also be effective, but it's really new to the market, so we don't really have a ton of data on that. For large perforations or delayed perforations that may cause diffuse peritonitis, surgery may be required. Post-polypectomy coagulation syndrome, so this occurs when a cautery injury causes actually a full thickness heat injury in the bowel wall, and you get a localized serosal inflammation and a localized peritonitis. The incidence is less than 1%, but again, the same risk factors, right? So right colon, polyp size greater than 2 centimeters, and a non-polypoidal morphology. And I'll tell you, for us, these are the most common polyps that we're removing, actually. I would say that more than half of the polyps that we're removing are on the right side of the colon, and they're almost always at least 2 centimeters in size. So some of the symptoms of that, fever, abdominal tenderness, maybe rebound, an elevated white count, it looks just like a perforation, right? So when someone comes into the ER and they have these numbers and these signs and symptoms, it's very concerning for a perforation. So it kind of mimics that. These usually occur within a few hours after the polypectomy, and they're generally treated with close observation, antibiotics, IV fluids, bowel rest. It's also important to note that when you're doing these, and I don't know if we've mentioned this before, but you should use CO2 insufflation for these cases. I think that CO2 insufflation is pretty universal. And I think for all colonoscopies, all endoscopies, really, we're using CO2 insufflation. And CO2 has been found to significantly reduce pneumoperitoneum post-procedure admissions, and it also decreases any kind of post-procedure pain. So finally, the last topic we're going to touch on is best practices for surveillance intervals. And this is really important. These were recommendations for follow-up after colonoscopy from the U.S. Multi-Society Task Force on Colorectal Cancer. And so there's been a change a few years ago. Have you guys switched over to these kind of newer recommendations for even small polyps? You generally follow these? Yes. Right. So the key here is most of the stuff that we're talking about today is really a piecemeal resection of an adenoma greater than two centimeters. And so the recommended interval for surveillance colonoscopy is six months. And I'm really glad that this is on paper, and this is the recommendation, because prior to this coming out, there was a little bit of willy-nilly-ness about when they should come back. Should it be six months? Should it be a year? And at least in our practice, it was a little less uniform. This has really nailed it down for bring them back in six months if it's piecemeal resection. There was a meta-analysis of 33 studies that found that the risk for recurrent neoplasia was 20% for piecemeal versus 3% for on-block resection. And that 20% seems to be something that we can't get away from. You saw lots of different techniques for EMR. And really, it seems like 20% is what the recurrence rate is or the residual neoplasia rate is. And so we're still working on how we can do that. But this information helped inform that recommendation. There was also a study assessing the rates of incomplete resection by immediately biopsying the area of assumed complete resection found. And it found that there was residual neoplasia in 20% of those with piecemeal and 8.4% with those who underwent on-block. So this is a study that they took everything out. They said, OK, I think it's all gone. And then they immediately biopsied that area. And even though they thought it all looked good, and endoscopically, with careful endoscopic inspection, they still found residual neoplasia in 20%. So several other studies have also shown a higher risk for recurrent neoplasia with polyps greater than 2 centimeters resected in piecemeal fashion. And so in some ways, when we're talking about the different techniques for removal, it's a little bit about how you want to do it and what your comfort level is. If you are trying to avoid complications and while still being able to remove this precancerous lesion, cold EMR can do that, but there's a higher risk potentially of residual tissue. Can that be removed in six months so that after a year, this thing is gone or even less than a year, this thing is gone? Sure. That might be it. Or on the other hand, removing lesions on block may be more effective at decreasing the risk of residual neoplasia. But is it worth that risk to you? And so that's for you to figure out and determine where your comfort level is. And also, it's in many ways a patient by patient basis. So the recommendations from the Multi-Society Task Force, first surveillance at six months. And then if that looks good, the second surveillance one year later. And if that looks good, three years out. And so this is six months, one year, three years. And this is the kind of thing that when you're consenting your patient or talking to your patient about what to expect for follow-up, this is oftentimes what's important for them because they're like, oh, do I need a colonoscopy every year now? Like no, the vast majority of people don't need a colonoscopy every year. But six months, one year, three years is kind of what you're going to tell them. And then they can, depending on what their neoplasia is at these intervals, they may be able to go out to five years. But this at minimum is kind of what you need to tell them. And then usually at our practice, we'll do the first at six months if that looks good. We'll send them back to their referring physicians, right? I mean, if you want to develop a referral practice for advanced lesion resection, you want to be a good partner to your referring physicians. And so do what needs to be done that they need your skill and expertise for. And then send those patients back to their local gastroenterologist. So in our practice, usually at six months, if things look pristine, we'll give them back to their local gastroenterologist for the one-year surveillance. If we still had to take stuff off at that time, then we'll keep them for one more round and then send them back. But these are patients that you frequently want to give back to whomever sent them for you so that you can continue to be doing advanced lesion resections rather than just surveillance colonoscopies. So in summary, it's important to review the information about the patient and the polyp in advance, exercise a robust informed consent process, use it as an opportunity to develop a relationship with the patient because it's really your only chance, ensure that you've made efforts at bowel prep optimization, and this could be, you know, changes with it. If you're not having great bowel preps, this could be changes at your endoscopy center level, you know, in terms of patient education, you know, prior to arrival, intensive education from nurses, videos, things like that. Those have all been shown to potentially improve bowel preps. Develop your plan for resection and how you anticipate managing the adverse events and the challenges, and then be really meticulous about following up on the pathology, communicating this with the patient, referring physician, and the follow-up recommended intervals for surveillance. Thanks. Thank you.

consent process

bowel prep

complications

surveillance intervals

advanced lesion resection

medical history