I have no financial relationships or commercial support to disclose. So my objectives today are to discuss the pre-procedure phase, the intra-procedure phase, and post-procedure phase of endoscopy. Our specialty in GI is unique compared to many other specialties in that we have both a large cognitive and procedural component to our disease management. And so as we think through colonoscopy, in order for you and beyond colonoscopy to be experts in our disease management, I think it's really important that you understand the in-depth aspects of procedures, even though you may not be performing them, to best explain both the cognitive and procedural aspects of our specialty. So I'll spend the next couple slides talking about timely scheduling, appropriate patient preparation selections, a brief comment on how we do our consults or targeted HMPs if you want, or if you wish, rather. As I talk to medical students, one of the things we teach them is now that you're on a specialty service or a consulting service, we want that targeted or focused HMP or consult so that it tells the story as it relates to GI. Yes, their overall health care management is important, but we want that targeted, focused consult so that we can best prepare the patient for any procedure. Bleeding risk assessment. Yesterday, Dr. Cole gave a very nice talk on bleeding risk assessment. Just a reminder to review medications when you're seeing patients in the clinic. Are they on thianoperidines? Are they on anticoagulants? Do they have cirrhosis and have thrombocytopenia? Do they have a bone marrow-related disease, and are they thrombocytopenic, and are they on an anticoagulant? So best to review this in the clinic, understand the bleeding risk assessment so we can best prepare the patient for endoscopy, specifically therapeutic procedures. And then I'll spend a slide on assessment for sedation. Once again, Aaron gave a great talk on assessment for sedation yesterday, but I think assessment and sedation is a talk that we can always hear reminders on. I don't think it's ever too much to repeat some of the comments on getting ready for sedation. So I think one of the things we learned from the pandemic is to reinforce how we think about the timely scheduling of patients. As you all remember, when we were in the thick of things early on, when elective procedures were suspended during the pandemic, I think we really improved our skill set at defining what was urgent, what was semi-urgent, and what was non-urgent. I think we should really take that lesson that we learned and move forward. So as we see patients in the clinic, those patients that have some rectal bleeding or weight loss, for instance, that is, in my mind, clearly more semi-urgent than someone who has diarrhea for a year. It's non-bloody and they have no other symptoms. So think carefully about the timeliness of scheduling the procedures, not only for making a timely diagnosis, but also to decrease the stress and anxiety of patients who perhaps they think or we think may have a more significant disease process. Patient selection, I think, is a very important part of our process. Just because we can do something doesn't mean we should. So we should think hard about who we choose for endoscopy. And remember, it is okay to say no if an endoscopy is not indicated. So as I think about who we choose, if I am going to do a colonoscopy or any procedure, will the results of that test change patient management? If the answer is yes, then that's a case when you would want to proceed. In cases where empiric therapy is indicated, we should give that therapy a try. And if it fails, then that would be an indication for colonoscopy. So patient comes in for rectal bleeding, you think they may have hemorrhoids, you give a trial of medication for hemorrhoids, they still have rectal bleeding, then proceed with your colonoscopy. If a therapeutic intervention is anticipated, then colonoscopy would be the correct choice. And as Vivek said in discussing informed consent, is there an alternative to our procedure, such as if we think a radiology test may help establish the diagnosis and has less risk to the patient, then perhaps we should proceed with a radiology procedure before asking the patient to undergo a more invasive procedure. In the days when it is very easy to order a test, keep in mind, as we'll see with complications, although they're rare, things do happen at the time of procedures and with colonoscopy, even in the best of hands. So think carefully about how you're going to proceed with patient selection. Some indications, just as a reminder, one of the more common indications for colonoscopy is a screening or surveillance procedure. So for colon cancer or colon polyps, lower GI bleeding is an indication for a colonoscopy. Lower GI symptoms. Some of these may have a little bit more time getting insurance coverage, but change in bowel habits, abdominal pain, any of those symptoms combined with weight loss. More and more due to the expanded use of abdominal imaging, we are seeing referrals for colonoscopy because of an abnormal imaging study, as you're all aware. Like any tests, CAT scan of the abdomen and pelvis is not perfect. It tends to overhaul thickening of the colon. So that is a common thing that we see these days for an indication for colonoscopy. To make the diagnosis of inflammatory bowel disease, we perform colonoscopy after a certain amount of time that a patient has inflammatory bowel disease to rule out dysplasia. So lots of biopsies to rule out dysplasia in people with long-term inflammatory bowel disease, specifically ulcerative colitis. And again, are we going to perform a therapeutic intervention? A common reason that we perform colonoscopy. As I alluded to in the timeliness and the appropriate indication or appropriate choice of patients, we have to be aware of contraindications in patients. So many of our patients are living longer, developing more comorbid disease, and they are very sick. So we want to make sure that when we order a procedure on a patient, that our benefits of the procedure outweigh the risks. If the risks start to outweigh the benefits, then either we find an alternative to colonoscopy, or perhaps we do not proceed with colonoscopy. The patient that comes in at age 70 that's on oxygen, they're on ethionapyridine, they're on Coumadin, and oh, by the way, they have sleep apnea, I'm giving an extreme example, clearly the risks of performing a screening colonoscopy or any test or screening for colon cancer outweigh the benefits. So make sure that we are doing, properly assessing the risks. If you're unable to obtain consent for a non-urgent procedure, that is a reason not to proceed. If patients come into the hospital, they're having a life-threatening bleed, they can't give consent, there's no family or POA to give consent, that's a different story. We proceed with the procedure with urgent or emergent consent, but if it's non-urgent and you cannot obtain consent, do not proceed. If we have a known or suspected perforation of the stomach, small intestine, colon, we should not be proceeding with an endoscopic procedure. More importantly, think of some acute abnormalities. A common thing we see in the hospital is patients ready for colonoscopy, we prep them, and the day of the preparation, their potassium is 2 or 2.1. So look for hospitalized patients for acute electrolyte abnormalities, look for drops in hemoglobin that may require transfusion prior to the procedure. Is the patient that's hospitalized been fairly ill and are they properly hydrated? Do they have intravascular volume repletion? So look for any acute abnormalities beyond the ones I mentioned, infectious abnormalities and other things that make us take a step back and say, maybe it is not the right time to perform this colonoscopy. And fulminant colitis, this would be another contraindication to colonoscopy. We talked a lot about bowel prep yesterday and diet. So clear liquid still is the mainstay, is the main diet for colonoscopy. But as I said yesterday, consider a low residue diet in the right population. Studies show us that it's a very effective diet, but people take liberties once you start letting them eat. So if you have a motivated patient who really thinks the diet will make a difference, certainly consider a low residue diet. Consumption review, as I mentioned earlier, the big ones are anticoagulants and thionoperidines, but also review to see if they're on sedatives, narcotics, psychiatric medications, all of which may affect how we proceed with sedation and we'll come back to that in a future slide. Vivek did a great job reviewing informed consent. The only comments I'll add is any opportunity you get to talk about the procedure, the indication, the procedure itself, the benefits and risks, do it. So when you're seeing a patient in the clinic, before you send them off, if they're going to have a procedure, discuss informed consent. When they get back to the endoscopy room, in my opinion, all endoscopists should do a verbal consent, again, reviewing the procedures, and then we get the formal consent signed. And it's very important that our staff in the endoscopy unit confirm that the consent is signed. That's an important quality indicator. And then bowel prep we talked about yesterday, a good bowel prep is really critical to endoscopy. It leads to higher quality endoscopic exams for colonoscopy. A few comments on sedation, just to reiterate what was said yesterday, in the United States right now, I would think at least 70, and we saw a number of 83% in our poll yesterday, so maybe as high as 80% of patients are undergoing deep sedation with monitored anesthesia care and an anesthesiologist or CRNA providing that sedation right now in the United States. Although in a smaller amount, like our group is using moderate sedation, where I would guess about 90% moderate sedation, about 10% deep sedation. Regardless of the type of sedation you're using, review the chart, review with the patient, have they had difficulty with prior sedation? Are they on narcotics? Are they using benzodiazepines? Will they become difficult to sedate if you're using moderate sedation and should they get deep sedation? A new wrinkle that we've experienced lately in states where marijuana use is legal, we're finding that these patients can be very difficult to sedate. And on Thursday, the timing was perfect. One of my partners was about ready to perform a colonoscopy, an upper endoscopy, and the marijuana is legal in Illinois. And the patient states he smokes marijuana frequently every day, at least three to four times. And my partner starts doing upper endoscopy first, and then he does his colonoscopy. He gave the patient 200 of fentanyl and 10 of Versed. He barely got the upper endoscopy done. And as I was looking in his room, I'd never seen this before, the patient was sitting up and actually on his phone answering text messages in between the upper endoscopy colonoscopy after getting 210. My partner was able to sedate him for the colonoscopy, but as he wheeled him out of the room, he was back on his phone and he was wide awake. So chronic marijuana use is, I think, a newer problem that we can face with moderate sedation. And if you talk to your anesthesiologist, they will tell you that patients using chronic marijuana require enormous doses of propofol, doses that are used to induce patients for anesthesia. So we're going to be challenging sedation cases with moderate and deep sedation. As I said, review the anxiety, if they have anxiety or depression, and are they on medications for these diseases? Assess the airway, trying to understand if we have some difficult airways, looking at the Malampati score, looking at the neck anatomy, and then assess patients that could be at risk for cardiopulmonary complications. And procedure. Our goal is to perform a high quality exam using screening colonoscopy as an example. Our goal is to find polyps, remove polyps, and prevent colon cancer. And so markers that we use, and I'll get into more detail as I have a quality slide near the end of the talk, part of performing a quality exam is starting with a good prep so that we can visualize the mucosa of the colon with a good prep. And then we want to understand what the sequel intubation rates are, what are appropriate withdrawal times, adenoma detection rates, and then understand complications. And all of these will define high performing colonoscopists. So what can you do as the provider seeing the patient prior to the procedure? I think one of the things that if you ask your endoscopist, you know, what type of colonoscopy or colonoscope would they like to use? Do they like to use adult colonoscopes? Do they like to use pediatric colonoscopes? And scope choice depends on a few things. One, it could be the endoscopist preference. Some prefer one over the other. But there are some circumstances where scope choice can make a difference. And I think you can have a good impact and make the endoscopist's job and patient's job a little bit easier at the time of endoscopy. Take a look at body habitus as your senior patient in the clinic. We know that middle-aged and older men that have a large abdominal obesity, these can be more difficult and challenging colonoscopies as the colon can become redundant and floppy. So that's where we may want to choose an adult colonoscope that has a little bit more resistance and doesn't bow or bend as much as we proceed with the colonoscopy. In older female patients that are thin that may have had hysterectomies, cholecystectomies where adhesions may play a role in distorting a small bowel and colon anatomy, perhaps that's the case where we may want to choose a more slim scope such as a pediatric scope. And these actually can make big differences in the technical aspect of the exam. Review the chart to see if they've had prior colonoscopy and if they did, what type of scope was used at prior colonoscopy. That's something that you can do and really make a difference in the outcome of the procedure and ease of procedure. Common device terms that you'll hear used. I think it's important that all of us understand the devices we use. So as we speak to patients, we can come across as very knowledgeable and the experts that we all are in this in our field. We use forceps for biopsies, snares to remove polyps, both hot and cold snares, and they are technically different snares available for cold technique and hot technique when thermal energy is used. We have baskets and nets to retrieve items. We have injection needles. We have hemostatic clips and then thermal therapy through electrocautery. So why should we really understand some of these things? Again, it's the more we understand about the cognitive and procedural aspect of our field, the better we come off for our patients as delivering high quality care and being good patient advocates. Tissue sampling is done with our forceps, and that leads to obviously pathology samples of which we will have to explain to the patient. Polypectomy, we have the cold technique removal, which is the overwhelming majority of polypectomies. Now, there's much less risk of post polypectomy bleeding, whether that's immediate or delayed with cold snares, as opposed to requiring a thermal therapy or a hot snare therapy in which we would start to use when polyps get larger than 10 millimeters, where there is an increased risk of post polypectomy bleeding, especially delayed post polypectomy bleeding. And we'll come back to that when we talk about complications. We have tattoos that we can use to mark the location of polyps or cancers to help guide the surgeon. And then we have endoscopic hemostasis tools available. We have argon plasma coagulation and radiofrequency ablation techniques, which can be used to treat radiation proctitis. We have electrocautery for our polypectomies, another form of thermal therapy, which is the ERBA unit. And then we have hemostatic clips to stop bleeding, close polyps to try to prevent bleeding, although the literature is not entirely clear on that. And then, unfortunately, we do have some post polypectomy perforations on large polyps. If they're identified immediately, those perforations can be closed with clip devices, both through the scope and over the scope clip devices. We can dilate strictures at the time of colonoscopy, and these are most commonly seen with anastomotic stricture. So people undergoing resections may need to undergo the therapeutic maneuver of balloon dilation. Stents are placed for colon cancer, perhaps for palliative reasons, or as part of a bridge to ultimate resection of the colonic lesion, if indicated. You'll hear the phrase endoscopic mucosal resection, and in colonoscopy, this typically applies to larger polyps, in which a number of techniques are used, including raising the polyp with saline or other solutions, using methylene blue to determine where the polyp tissue ends compared to normal tissue. A tattoo could be used to mark polypectomy with thermal therapy. Clips may be used. So this is a very good technique to remove large polyps and prevent people from having to undergo an operative procedure. And one of the most favorite things all endoscopists do, and that is place a decompression tube for colonic ileus. What about complications? Thankfully, in colonoscopy, as with upper endoscopy, the risk of serious complication is low. The most common complications we see are cardiopulmonary anediology, and they range from the very simple, from a technical standpoint, if people become hypoxic during colonoscopy and require oxygen, technically, that's an adverse event. It's a minor adverse event because most people respond very well to oxygen, all the way to a more serious cardiopulmonary complication, such as aspiration pneumonia. A way we can try to minimize cardiopulmonary complications is with a good pre-anesthesia risk assessment and involving the anesthesia service when needed. If we think patients are at an increased cardiopulmonary risk, that is certainly time to get our anesthesia team involved and always appropriate pre, intra, and post procedure monitoring. So what about some specific complications related to GI? So we can see immediate post polypectomy bleeding. The polyp is removed, and we can see the range of minor bleeding all the way to a vessel being exposed and having some more arterial type of bleeding. Options available are epinephrine injection, and again, I think a combination therapy works very nicely here. By injecting epinephrine, you can try to slow down the feeding, vasoconstrict the feeding vessels, which can slow down the bleeding and allow you to better identify the specific bleeding area. I think most of us would choose hemostatic clips to treat post polypectomy, immediate post polypectomy bleeding. The thought of adding more thermal therapy to an area that has already received thermal therapy from the polypectomy, it's just, it doesn't intuitively make sense. Hemostatic clips have really helped better treat immediate post polypectomy bleeding. So that's something we could see at the time of colonoscopy. Perforation is rare. Mechanisms of perforation include mechanical trauma. It's technically a difficult exam. There's some resistance to the scope. There's some bowing of the scope, and that's when we can unfortunately breach the colon wall. Pre-CO2 use, we had the concern of barotrauma causing a perforation. The classic example would be that there's a distal colon cancer. So in the rectum or a sigmoid, rectal sigmoid colon cancer, trying to get around it, the endoscopy, the endoscopist infuses a lot of air. That air gets up into the colon. It's now trapped. It can't get out. And unfortunately, the cecum can't decompress into the small bowel, and you actually run the risk of barotrauma. Most of the barotrauma perforations are actually in the cecum and proximal colon, as opposed to the distal colon. And then we can have electrocautory injury that we can see with large polyp removals. But with the introduction of hemoclips years ago, we can actually close those perforations, and that would be the definitive therapy in many of these patients. They may spend the night in the hospital, get some antibiotics, go home the next day. And there have been patients we've actually sent home on oral antibiotics. There's some literature to support that that do very well with the closing of the perforation immediately. Some post-procedure things to consider as we talk to our patients, especially from the APP standpoint, we have to disseminate the findings. So this is where that good understanding of the cognitive and procedural aspect of the procedure comes into play. We need a good understanding of the medications that we will use, ranging from complicated medications to treat inflammatory bowel disease, all the way to simple treatments for hemorrhoids. So we need to understand both the cognitive and procedural aspect of these medications. Follow-up and pathology results. So we need to be able to explain the non-polyp pathology, explain the finding of IBD at pathology, explain the finding of IBD at colonoscopy, and then wrap everything up for the patient to say, you now have ulcerative colitis, and here's how we're going to treat you now that we have made a diagnosis endoscopically and pathologically. And another example would be polyps. The most important thing as far as post-procedure polyps is to enroll that patient into the proper surveillance program. We have up-to-date guidelines. I think they came out in early 2020 that changed surveillance protocols for patients. And so we need a good understanding of the surveillance program guidelines so that we perform colonoscopy at appropriate intervals, and we do not overperform colonoscopy at inappropriate intervals. As I mentioned earlier, we're going to touch on one slide for quality indicators. I think it's very important for all practices to participate in a quality database project. The ASGE, in conjunction with ACG, has a very nice benchmarking project called GI Quick. So I hope all of your practices participate in quality projects. From the perspective of advanced practice providers, I think these are some numbers you should know as you discuss colonoscopy with your patients. The accepted adenoma detection rates nationally are 20% for women and 30% for men. I think most of us would agree that this is fairly low-hanging fruit. If you look at high-performing endoscopic practices, they are easily into the 40% to 50% range for adenoma detection rate. But these are the minimums that you can discuss with your patients. The current recommendation for CEQL intubation rate, it should be greater than 95%. Once again, if you look at high-performing practices and high-performing endoscopists, they are easily over 98%, 99% in CEQL intubation rate. As far as post-polypectomy bleeding, you're seeing a patient in the clinic. They have a large polyp diagnosed at an outside facility, and they're coming to your practice because your practice is a high-performing practice, and your endoscopist is going to remove a large polyp. You could tell them that the risk for bleeding ranges from about 1 in 500 to 1 in 1,000. And once again, thankfully, perforation rate is very low, anywhere from 0.1% to 0.1%, so very low perforation rate. And you can reinforce the patients and re-insure patients that the risk of perforation is very low with colonoscopic procedures. So, some of the more common complications we see, a post-polypectomy would be post-polypectomy bleeding. The classic presentation of post-polypectomy bleeding occurs when thermal therapy is used to remove a polyp. We rarely see it with cold-snare polypectomy. It has occurred, but it's pretty rare. Typical timeframe is about five to seven days when the S-scar or the surface healing process falls off, thereby exposing an underlying vessel. Over the 4th of July weekend, I had a patient transferred in from an outside institution. Poor guy was in town for a wedding. He had a colonoscopy about five days before in California. His diurnal peritoneum was restarted, and poor guy ends up in the ER in Rockford with a post-polypectomy bleed. I did his colonoscopy, and he had a cecal polyp that had a vessel that at the time was non-bleeding, but clearly was the post-polypectomy bleeding source. So, I clipped that, and he went on his merry way very quickly. Delayed perforations are unusual. Most of the time when we see a post-polypectomy, perforation is immediate, but the main way we see a delayed perforation is with barrel trauma. Again, pre-CO2, it was more likely to occur. With CO2, barrel trauma is less likely, but there have been some case reports with CO2 where there's been barrel trauma perforation. But thankfully, with the use of CO2, we're seeing less chance of barrel trauma perforation. But if someone that had a colonoscope today and three days later, or 24 hours, 48 hours later, has significant abdominal pain, don't forget about the possibility of barrel trauma because it is a delayed presentation. Post-polypectomy syndrome, something that is not common, but we do see, especially in larger polyps that may require more thermal therapy to remove the polyp. Post-polypectomy syndrome is secondary to electrocautory injury or thermal therapy to the bowel wall. Essentially, what we are getting is a transmural burn, so a through and through burn of the colon wall, but no perforation. And they essentially have a focal peritonitis, again, without perforation, typically no abscess. Occasionally, there might be some fluid outside the wall from inflammatory response. They present with fever, tenderness, specifically more of a point tenderness, and leukocytosis. The management is pretty straightforward. IV fluids, IV antibiotics, and bowel rest, and they do very, very well. Infections related to endoscopy are very rare, especially if your unit is following the proper guidelines for reprocessing. It's something we just don't see. It's a very rare event to see infections related to the procedure itself. So, pearls to think about. It's important to think about the phases of colonoscopy, the pre-, intra-, and post-phase. It allows us to have that complete knowledge of cognitive and procedural aspects of disease management. Be smart about patient selection for procedures and sedation. Understand their risk factors and make sure we address those prior to ordering the procedures. Understand the immediate and post-procedure complications. And although we don't see the post-polypectomy syndrome much, when that patient calls a few days after colonoscopy and has some abdominal pain, it isn't feeling well, that should be one of the first things that pops into your mind, especially if they have some fever and they've had a polypectomy, that perhaps they have a post-polypectomy syndrome. And I think the most important thing I've learned over the years about procedures in general and colonoscopy, because it's the most common thing we do, is will performing the procedure change the management and outcome of the patient? Again, just because we can do something doesn't mean we should. We should choose wisely. And many times, one of my partners who's now retired told me, and it rings very true, many times the most difficult thing to do in medicine is to say no. And sometimes we have to say no. The 85-year-old or 86-year-old patient who comes to see me, who's very healthy and wants another colonoscopy, I'm going to do everything I can to convince them not to. And if they want it, and I feel strongly that they shouldn't do it, I will say no, and they perhaps will find somebody to do it. But think long and hard about doing the procedure, the right indication, and don't be afraid to say no. Thank you. I'll now hand off the talk back to Aaron, who's going to talk about some of the basics of ERCP in the U.S.

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