Dr. Vickery, someone asks, what exactly does adenoma detection rate mean, and then why are the rates so low, or the performance targets so low? Sure. So, adenoma detection rate is, if you look at a population of average risk patients that undergo screening colonoscopy, is the minimum percentage of patients in which we should find an adenoma. So, right now, it's 25% overall, 20% women, 30% for men. These numbers actually were just adjusted within the last few years, and although they seem low, they are definitely improving. All of the numbers that we use in our guidelines are based on evidence-based studies, and studies continue to accumulate data. I think all of us from the endoscopic side would agree that these numbers will likely continue to shift upwardly. These numbers tend to shift slowly, but I wouldn't be surprised in the next few years if we see a 25 to 35% range, with 30 being average. And as I alluded to earlier, I'm very confident that all the physicians on this meeting and their groups are performing at a higher level. In our group, we're about, Aaron, about 45%, is that right, in our group overall? Yeah, all of our providers range between 45 and 55%. And that is true for all the high-quality practices and experienced endoscopists, good prep, you know, a lot of things have to go in place for that, but those numbers are exactly right there. Other questions? Yeah, let's move to Dr. Shields, and we have a question about patient positioning and ERCP Are you able to position the patient both prone and supine? Yeah, that's a good question. You can perform ERCP in either the prone or the supine position. I can tell you that the difficulty with the supine positioning is, as an endoscopist, you often end up almost turning your back to the patient, and you end up looking over your left shoulder at all the screens. And by the end of a supine position patient, my neck is sore. So I prefer to perform in the prone position. I know there are some places where they exclusively do it in the supine position. I think they must have a better tolerance towards craning their neck to the left than I do. I guess maybe some of the other ERCPS on the panel can comment on that. No, I think, Aaron, you nailed it. It is a little bit harder in my experience to do it supine. Pregnant patients in the second trimester, and if you're forced to do it in the first trimester, typically we'll do that. In the third trimester, we don't want to go prone. We want to go left lateral. We want to go prone or supine. We want to go left lateral in the third trimester. But other cases where post-surgical cases in the ICU, bedside ERCPs, patients who have multiple drains coming out, have significant BMI or cardiorespiratory compromise where putting them on the prone position will be hard on the patient. So we have a relatively low threshold based on the anesthesia request and the patient condition to go supine. But many places in Europe, I know colleagues who have trained entirely on supine, and that's how they practice in different parts of this country. So it's an interesting question when it comes up. I think the main issue here is that for a competent experienced endoscopist, one should be able to or needs to be able to deliver the procedure pretty much in any position. I do not like the left lateral position because it changes the orientation of the bile and pancreatic ducts and sets you up for a little bit of a problem in cannulating. But John, do you have any comments on this issue? Yeah, I do actually. Thanks, Vivek and Aaron. Just to provide some anatomical understanding as to why ERCP is performed traditionally in the prone position, it has to do with the fact that if there's a patient's on their back, then the fluid tends to pool onto your lens. So you're constantly having to aspirate. The thing is that by putting the patient on their belly, basically the fluoroscopy table splints the belly and puts pressure on it. And so as your scope is navigating, it actually is kind of like doing a colonoscopy and putting pressure on the sigmoid. It keeps the scope from looping. Remember that a side viewing duodenoscope, unlike an upper endoscope or a colonoscope, the lens is on the side. So if you turn the patient 180 degrees from being on their belly to being on their back, then you have to compensate for that. As Dr. Shields was saying, the endoscopist has to turn 180 degrees as well because the lens is on the side. So, you know, where something is makes a difference in terms of how the scope is oriented. At Mayo Clinic, the anesthesia team unfortunately really loves supine position because it's easy for them. So we've actually organized our ERCP unit so that the boom that the monitors are mounted on can actually swing to the other way so that I don't have to crane my neck, but I still have my back to the patient. And it is ergonomically challenging to turn your wrist, particularly if you're short like I am and not pulling up on the scope. So it's ergonomically challenging for the endoscopist to perform the procedure with the patient on the back, but we can do it. Thank you. I have a provocative question here as we head to the four o'clock time. What do you think of primary care providers performing endoscopies? Who wants to take that one? I think we can start with that. I think about only about half or maybe 60% of endoscopies actually performed by a gastroenterologist. So there are non-GI endoscopists. They tend to be general surgeons, colorectal surgeons. I think nowadays less and less internal medicine doctors and family practitioners. I think the question really, Vivek, is could they obtain the proper training, meet the minimum goals by the guidelines to ultimately perform quality exam? So I don't know that necessarily any of us would be against non-gastroenterologists performing endoscopy, but they certainly need to undergo rigorous training and follow the quality standards that we all follow. Unfortunately, we know that that isn't always true. Yes. I mean, I think your answer covers all the high points on that topic. The only additional thing I will add is that we are now, we have now entered the era of what we call single use or disposable endoscopy, including now the availability of a disposable, so to speak, SLIM endoscope. So in years to come, we don't know if the appropriately inclined candidate out there with the access issues that we have, might this paradigm emerge a little bit in a different way where you have a primary care physician saving up a day or half a day to do transnasal endoscopy for their reflux patients in middle America, where with proper training, with proper guidance and so forth, that'll just become like a near exam. I don't know that might happen, but the relative smallness of the footprint, the availability of single use scopes and the way these things go and the continued access issues that we have, you know, it might lend itself to that paradigm in the future, but there are no veritable objections to that question. Any other comments? I think some of it depends like you're suggesting on what resources are or are not available, particularly in rural areas. You know, I'm not far from some extremely rural areas and, you know, it's tough for patients to, you know, drive three or four hundred miles just to get screened, particularly if somebody has to take a day off to drive them back and forth because they're sedated. Yet on the other hand, like we described earlier, the procedure itself is only a small part of the overall use of endoscopy in disease management and prevention. And as a result, the education requires more than just teaching the technical aspects of, you know, screening and diagnostic endoscopy and what limits you're going to set. You know, many times I think as endoscopists, we're expected if we actually do find something to know what to do about it and not have the patient undergo anesthesia a second time or to come back for another colonoscopy, to have a polyp taken off because when you did the first one, you didn't know how to take it off. And so, you know, I think there are a lot of caveats, a lot of training would have to include not just the simple procedure, but the sort of what to do. And I think the what to do is the complex part. And that's a lot of what we're underscoring for you is you don't know what you're going to find. You know, it's like that box of chocolates thing. And as a result, you kind of need to be prepared for just about anything and know how to handle it properly. And that's the tough part of the learning curve, I think. Absolutely correct. There's an easier question here, which says, what is the cap and the cap EMR for? The cap is to suction the tumor or the polyp and then keep it in the barrel of the cap while you apply a snare at the bottom of it. So kind of a poor, poor person's full thickness device, so to speak. But the cap's been in existence for nearly more than two decades and has been used very well, if you use very effectively, if you use the correct technique. Other questions, Eden? Yes. Is the treatment of perforation via endosurcharing, suturing, endovac, et cetera, something there is standard educational material for? Though statistically rare, I see this very commonly, weekly, this person indicates in the hospital setting. So the treatment of perforation. Right. So endoscopic management of iatrogenic perforation or intentional procedures that create perforation, such as full thickness resection, is pretty well established now in the vast majority of cases. There are still some cases, and you can use endoscopic suturing, full thickness clips, standard endoclips or a combination thereof. But there are still areas where we are just simply unable to close larger defects or defects in difficult locations or in situations where the patient's pathology prevents us to endoscopically, you know, reliably close those those defects because of disease states, tissue fragility, and or the patient's clinical status. So it's a paradigm that has evolved very significantly. But there is some work to do in there as well. The endovac is something that's been used by our European and Asian colleagues with great efficacy. It does help in the management of complicated perforations where there's a periperforation abscess or septicemia that is that is in place. And it really, you know, there's some good data, initial data to suggest that it really works. Wonderful. And yeah, we have we still have time for more questions. The the faculty have been answering a lot of questions. So if you had a question submitted, do check the answered questions. And you may have already had your question answered. We are trying to read some of these live as well. Next question is, do you recommend a repeat EGD for biopsy negative clean based superficial gastric ulcer? In other words, do you rescope all gastric ulcers? I think that's Dr. Martin. Would he address that? Sorry, I was actually answering. Sorry about that. Let me reread it. Yeah, let me read it. Do you recommend repeat EGD for biopsy negative clean based superficial gastric ulcer? In other words, do you rescope all gastric ulcers? Yeah, that's a that's actually a nuanced answer that I'm going to give you to that one, because, you know, the old mantra was that any gastric ulcer needed a routine relook because it could be gastric cancer. The statistics, you know, from a disease managed management standpoint have changed. And so I think from a clinical perspective, if you had something that was pretty clearly from history and from the morphology, you know, very, very likely to be, say, aspirin induced gastropathy and not, you know, a gastric adenocarcinoma and, you know, a very superficial ulcer or erosion in the antrum with lots of, you know, erythematous spots and so forth. And somebody who's eating aspirin for various reasons or NSAIDs on top of aspirin is very likely to be that. And if you take the biopsies and the biopsies demonstrate findings on histology consistent with, you know, NSAID or aspirin induced gastropathy, then I think you have your answer. And it would be really difficult to justify, you know, routine repeat endoscopy to make sure that that's healing. However, as will, you know, possibly be addressed by Dr. Shields and his upcoming talk, the nuance here is that, you know, there's sort of clinical common sense and sense of smell, which still matters and is still the fun part of medicine and the medical legal climate of the area in which you practice. I practice in a rural part of Minnesota where pretty much nobody sues anybody else. You know, they don't have time for that. They need to get back to the farm. That's what they're concerned about is, you know, getting planting done and harvest in. However, you know, I spent earlier parts of my career practicing in downtown Chicago and in downtown Pittsburgh, which are both extremely litigious areas. And I can tell you that, you know, that influences how I ultimately practice because I have no choice. And so in those more litigious environments, I might be more likely to err on the side of a repeating a procedure that, you know, if it were just the clinical aspect of it, I might really dissuade myself from repeating. I hope that sounds fair and explanatory.

adenoma detection rate

colonoscopies

ADR targets

patient positioning

endoscopic retrograde cholangiopancreatography (ERCP)