Our goal over the next session really is to share with you practical tips to improve colonoscopy performance and outcomes, and the available evidence and rationale to support this. I'm delighted to introduce our wonderful panel. I'm joined by Dr. Douglas Rex from Indiana University and ASGE past president, Dr. Eveline Decker from Amsterdam Medical Center, Dr. Roy Sotinko from San Francisco VA. So the structure of this session will be starting with a video case discussion, followed by two lectures, and then a heated debate. So let's go ahead and start with the video case discussion. All right. We have a 64-year-old man who had a recent colonoscopy for a positive coligard. The colon was redundant, and with that endoscopist, the scope only reached the hepatic flexure. CT colonography showed a possible mass in the ileocecal valve. And so now he is on your schedule for you to do the colonoscopy. So I pose to you the panel, and I think I'll start with you, Doug. How would you approach this case, and what strategies might you consider a priori and during? So if you have a previous incomplete colonoscopy, the most useful thing is to classify the problem as either a bad sigmoid or a redundant colon. Those are the two main choices. Occasionally, it's a hernia. And for a redundant colon, the best scope is a standard scope because it resists looping. And the most important technical maneuver, I would say, is to go in underwater so that you keep the colon narrower and shorter, and you've got enough scope left when you get over to the right colon to go ahead and get into the cecum. Great. All right. So you perform the colonoscopy, as Doug nicely outlined. You're barely able to reach the valve with the scope fully inserted, but you do see this lesion, which is very difficult to approach closely and to position optimally. So the lesion is in the cecal base. And while this is playing, I invite Eveline. Tell us how you would characterize this lesion, and what about the risk of cancer here? Yes. So we are a little bit distant, and we are just using white light. So I would have preferred to clean maybe a little bit better. You're trying to here, I think. And also have some virtual chromoendoscopy. But it looks like a laterally spreading lesion, all granular. I don't see any bulky parts. And looking at the mucosal pattern, to me, it seems a nice 2 and a J, not 2A. So it looks to me very benign. And the chance of this such a lesion in the cecum to be, or in the right colon to harbor invisible invasive growth is very, very low. In the study from Australia, probably up to 0.7%, to be exact. Great. So there's a decision point here in terms of management. Which of the following might you consider employing? I'll let you guys in the audience read through this, but I'd invite Roy to maybe give your approach to how you would do it. I think the first thing you should try to do would be to reintubate with abdominal pressure. Many units don't have the overtube, so I'm not dependent on that. So repositioning abdominal pressure would be the choice for me. Great. So it sounds like there's a vote for abdominal pressure. Anybody on the panel offer anything else that you might do differently or in addition? I mean, I think the right thing to do would be to go in with water from the get-go. You know what the problem is. And so just again, so you have enough scope. Abdominal pressure is really important. A lot of these patients have a really high BMI in the U.S. And sometimes you need a couple of people pushing to try to find all the loops. You try every trick in the book. Sometimes having a tech massage the belly to sort of catch the side of the scope and get it to lunge forward. But definitely to get this thing out, you want to get right down on top of it and get in good working position. Yeah. Great. All right. So here you'll see that injunction is performed. Roy, do you want to narrate or discuss any highlights here as we watch? So this lesion is considered a laterally spreading tumor, homogeneous granular. There is no one nodule. So the way you think about this is that you have a bunch of small or diminutive polyps sitting next to one another. And the risk of them containing cancer, even in aggregate, is very, very low. I think even like 0.5% is quite high still. So here, because the risk of cancer is low, then the way of thinking it would be like, oh, this one could be resected in piecemeal fashion. So I have one comment. And that was already what I considered in the first image. I would like to know exactly where the appendage orifice is, because if that is situated within this lesion, it really definitely takes a different approach. And you have to make sure you are able to remove it. If it's in the middle, that might really be a problem and you might need a hybrid technique, for example. Yeah, I think you raise a very good point. All right. Next decision point. You can see this lesion, you've characterized it. There's a very low risk of in situ cancer, invasive cancer. How might you remove this? Hot, cold EMR, we'll talk about this in more detail later in the session, but Doug, maybe I'll throw that out to you. General thoughts. So this is a lesion that would fall into the group that you could, I think, remove by cold EMR, because it's granular, so it's probably going to lift very nicely. It's not going to have much in the way of submucosal fibrosis to make the cold snare bounce off it. It has a very low risk of cancer. And other considerations would come in play here. For one, if the advantage of cold is a very, very low risk of a complication, the disadvantage is a higher recurrence rate. So if this patient was referred to you and they're going back home and you remove it hot, you might worry that the doctor would not be able to get up there to manage a complication. I will say for cold EMR, you really have to get down on top of the lesion very well to exert pressure on it with the snare. One of the problems with cold resection is you cut more superficially. So if you're far away from a lesion, you can't exert the same force. If the snare is way outside, you can't get the same force as if you've got the scope right where you need it to be, a couple of centimeters away from the lesion, and you can press the snare down into the submucosa. So I think those are all considerations. Bottom line, either one would be okay. Sometimes things come into play like, do you think the patient's actually going to come back? I don't like to do, you know, cold EMRs on people that act like, you know, it took a lot of convincing to get them here the first time, and I'm not sure they're going to come back for the follow-up because the recurrence rate for large adenomas is clearly higher. All right. We'll have more discussion on this later. There is an area of unexpected fibrosis that's encountered and snaring is difficult. Eveline, how would you approach this? Yeah, this is, it looks a little bit fibrosed in the middle, and that's what quite often happens in the right side of the colon, right, especially near the cecum. Still, I mean, we did not have a suspicion of invasive growth, so it wouldn't worry me in that sense, but we need to make sure we resect it radically. So I would continue trying to snare these pieces, and as much as I can, and if I leave something like, for example, in the middle that's really, really fibrosed, I would suggest to use the avulsion technique of taking large biopsies and then using an additive ablation technique like your tip snare or even an APC, but I usually like my tips. Roy? You've done very well because you cut from the edges, and then you're moving towards the center. So here you encounter a little bit of fibrosis. You look at the surface. This is not a malignant lesion, so you're going to say, okay, this is just fibrosis from the lesion, not a desmoplastic reaction. I'm going to inject more. I'm going to describe later about the dynamic injection, semi-causal injection, that will be helpful. The thing that could cause trouble here is that if you try to use a big snare and try to capture a lot of tissue. So here the approach is like actually to use a smaller snare and just like keep going towards the left side of the lesion. Really great points. So we did talk about this here. I'll move ahead for the sake of time. And just to demonstrate, obviously there's been a cap on throughout this procedure. Doug, do you want to explain what's going on here as we wrap up? Yeah, this is the cap technique where you're using the distal attachment there, which you have only sticking out about three millimeters, four millimeters at the most. Some people put it out farther, but I like it really short. And you lay a small snare over the area that you want to remove. And then you suck that tissue up through the snare into that cap. At that point, you're blind. You close on it, release the suction, and cut through the tissue. So this is a way to try to avoid having to do too much avulsion. I absolutely agree that if you have any tissue that's left at the end of the snare resection, you never want to ablate it. We've sort of abandoned ablation. So we would go to avulsion. There we've released the suction and go ahead and transect through that. And you can see that that allows you to keep the snare process. And it's very common after you get out of that fibrotic area, you get back into some relatively easy snaring. So this is a beautifully complete resection, soft take-ups, snare tip soft coag was completed. So we'll wrap up this case now here. But the defect looks good. It's been inspected. There's no muscle injury and clip closure is performed. That will be addressed more in the large pop session this afternoon and any controversies there. So let's move on now. And I invite you, Doug, to come up here and share your top 10 tips.

incomplete colonoscopy

redundant colon

lesion characteristics

lesion removal techniques

cap technique