The Jerry Way Endowment supports ASGE programs and activities focused on GI endoscopy education research and mentoring, including an annual lecture to be presented to digestive disease weight beginning now. Jerry, our past president of ASGE Rudolf Schindler award winner, president of WEO founding member and president of of NYSGE educator to legions mentors are so many. You've done live cases in every continent except Antarctica I don't think you've done any cases in Antarctica, or yet. But really inspiring all of us were so honored to have him here to come and present the first Jerry way endowed lecture. I've enjoyed the course so far it's been terrific. And this part on colonoscopy is near and dear to my heart. It's a distinct honor to introduce the first inaugural Jerry way and doubt lecture at this course. It really recognizes my 60 years of learning, teaching and performing endoscopy mainly colonoscopy. I want to especially thank the ASGE for this incredible honor, and all those who have given their generous support, but I also want to especially thank Dr. Klaus Mergener, Dr. Jonathan Cohen, and Dr. David Greenwald for bringing this to fruition. It's been a long siege of over 60 years of my doing colonoscopy. It's now time to introduce the inaugural lecture my friend and colleague, Dr. Roy Satick know who is going to talk on maximize safety maximize the efficiency and success of polypectomy. He is a practitioner, a researcher, a teacher, and an extraordinary educator. So let's join together in in welcoming Roy, to give the first inaugural Jerry way and doubt lecture. Thank you very much, Jerry, for this honor that's truly unexpected. Thank you to the ASGE for selecting me for to give this inaugural lecture. I'm deeply honored, it's unthinkable. So today, I would like to share some of our thoughts about polypectomy efficiency and success. And to be honest, this lecture has been about five to seven years in the making. In the first part of the lecture, I actually will describe a newer, better way to learn how to perform, through the training, polypectomy, through the detection and characterization of the flat lesions, and then maximizing the submucosal injection. And then I will talk briefly about how to recognize the malignant polyp. I will not describe this diagram but I will talk about mainly the yellow and orange part, which is the lab for the larger, more than one centimeter polyp. This was our work that took about a decade in the making, when we described in 2008 that the flat lesions exist in the Western countries in the United States. There was a brief issue with problem with this publication. There was the method section that the editorial took out. And there was a couple of paragraphs, and we actually didn't know how to describe it better, except to say that it took us very dedicated colonoscopy researchers about 1500 colonoscopies to get to the study state to find the flat lesion consistently, which is about 8 to 10% of the patients. And if you look at the training of fellows today, they probably performed somewhere about 300 to 400, and they are going to have a lot of adenoma mystery. It is unclear if we actually can gain the rest of the skills that's needed when we have a very busy practice. And recognizing and interpreting lesions actually has been an enigma in endoscopy until today. For a number of years, we tried to do different things. We created multiple videos, we published, we gave talks, and things didn't seem to change. It's still needing a lot of efforts to train our trainees how to find these flat lesions. And then somewhere about five years ago, we said, well, maybe we should ask ourselves if our education science that's used in endoscopy is actually wrong. Is it possible that we actually use something that's completely outdated? And it turned out that as we were busy expanding endoscopy for the past 20 years, there is this science of expertise whereby it is now known that people develop expertise through these things called deliberate practice and feedback. It is not the apprentice base, it is not the unconscious competence or incompetence, whatever, in endoscopy. It is very different than that. And then we asked, who is it in the country that is leading this effort? And the picture is depicted here. He's a Nobel Prize winner in physics in the same institution. So we called him cold. We asked him this question. Why is it that our trainees couldn't recognize the two large SSL lesions on the top? And why is it that a colleague actually biopsied next to the lesions in an IBD colitis that a year later became a T2 cancer? Why is it that they couldn't see these lesions? And he said, Roy, I know a little bit, a fairly bit about this issue. And he sent us back this article. Go read this article. It's about sexing the day-old chicks. But then if you go to the first sentence, it says that sexing the day-old chicks is a big problem. It requires many, many years to gain the expertise. It is no difference than us trying to understand what we see during endoscopy. But this paper is a randomized trial in 1987 or so. And it says that if you just teach the fellows, the learners, using published tables, they are not going to become like the experts. But if you teach using this technique that is now called the expert performance approach, then they immediately become like the experts. So this is what it is in practice. We find an expert. We actually interrogate the mind as the expert is looking at the sex of the chickens or looking at the polyp. What is it that they are thinking? And really deconstructed it to the very, very basic parts. And then try to understand. So, okay, they use these concepts. They use these decisions. And then you create activities or simulations for the mind to again and again understand these different decisions that they are making. And then you monitor this. You give a lot of feedback. And then, boom, suddenly they become very much closer to the experts. So I'm going to share this concept using these three steps that I wanted to talk about. And here is the systematic approach to the detection and characterization of the flat polyps. When we see the polyp, it is just like when we see a patient in a clinic. We listen. We look. We shake hands. And we don't really just put a stethoscope on their chest. We don't use the NBI right on. That is the diagnostic part. And then we use some kind of mental model. So the classification here helps us to have this mental model. Oh, that is the granular homogeneous. Oh, that means that the risk of cancer is small. I can cut it into small pieces. And then everything will be good. So that's how it should be. So play this video, please. So this is the expert performance as I was performing this. Vessel. Vessel. Dot. Dot. Dot. Dot. Lines. Lines. Lines. Lines. Come down here. This area has lines. Everything is good. Lines. Come back. Back. Back. Back. Lines. Lines. Lines. Oops. Pole is interrupted. Pole is interrupted. Look at the border. Look at the border. There's a lesion. Lesion goes to here where the lines don't cross. Lines. Lines there. So that's normal. There's lesion. There's lesion. Look at the border. Look at the border. You may have to look at behind the pole. Come back slightly. Slowly. Lesion. Lesion. Lesion. Lesion. Lesion. Lesion. And then, okay, there's a lesion. There's a lesion. Lines is interrupted. Okay, now we're going to make the diagnosis. Case to NBI. NBI, please. Okay, let's go through the surface. Type 2. Nice. Type 2. Nice. Type 2. Nice. Type 2. Surrounding white. Nice. Type 2. Border is still on top there. Border is seen. And now we can do therapy. We are going to do dynamic from the proximal side and then the wrist. So here, note that the experts, when we interviewed them, they actually were not looking for polyps. They were like following these lines, which is the innominate grooves. Come back. That are interrupted when there is a lesion. So the adenomas, the flat lesions, they do not have these lines. So just following these lines and then saying, okay, where are the lines interrupted? And that's when you start saying, okay, I need to find the border. I need to see what size it is. And then I need to characterize the lesions. If you try to find flat lesions as you look, it's going to be a very tiring experience of doing a colonoscopy. Another part that we look at is that we look at the smoothness of the folds. Does the folds look like naturally curved? So here, if you look at 6 o'clock, there is actually a lesion, a T1 lesion in the second fold from closest to us. The same thing here. You look at almost at the center. You look at that fold. Fold, fold, fold should be smooth. And then why is that fold interrupted with this bumpiness? And then you say, there is a flat lesion there. I need to pay more attention to that flat lesion. Here, you see the same thing. The folds that you were expecting to be smooth, contiguous, and suddenly it's like bitten by something. And that is a T1 cancer. Now, a fold that's missing, like the cookie monster has gotten in there and bit a piece of it, is quite dangerous. That's when you have a depressed lesion or a lesion that's more than just mucosal. So what is deliberate practice and feedback? Deliberate practice is really when you do the practice, the exercises, step by step with a focus, with a trainer that tells you what it is and why certain thing is not. And then you do it again and again. Once you master that level, you go to the next level. And it can be done for endoscopy. We've done it multiple times using the pole EV. We don't have time to talk about this, but this could be very much a practice. So let's talk about the expert performance about submucosal injection. And really, we call it a dynamic injection. What you want to do is that you want the tip of the needle to move up, usually, or to move to the side. And you do it very dynamically. So I'm going to share it with you. Play the video, please. Inject how many cc, how many cc? 10. 10, enough. Needle back. So here's the deconstruction of my dynamic injection. Finally, at the bottom of the leecher. This way. Now look up. Inject. Look up. Look up, look to the left now. Now bring it to this side. Drop it this way. Drop it this way. Look to the left. Okay, now. So here, what we are doing is that we are scoping the subucosal injection. And with this amount of subucosal injection, you really don't have to be worried about whether you're going to use cold, hot. You're going to be like an endoscopic surgeon. You're going to cut this. You're going to cut it. And then if you need to apply cautery, there is enough subucosal space. So sometimes you need to pull the needle back. And here I'm going to share with you the performance of cutting. Play the video, please. Okay, good. Good. Slowly now. Slowly. Okay, good. Look down. Okay, now. Okay, close. Now, there is a very important spot here. We lift up. Open just minimally. We open slightly. And then we close again. So that movement is very important. Because then we don't cut as deep. Okay, I think you got the idea. Okay, I'm going to go to the next one. The next topic is really just going to be the next two minutes to talk about how to recognize malignant polyp using the same approach. So here, when we look at the polyp that could be malignant, these are the larger ones, we actually don't use the NBI until the last 10 seconds. We are just looking at the appearance. So one of the most important appearances is fold convergence. You think of it as an octopus. So the tentacles are coming towards the body and it becomes larger. There shouldn't be like a fold going like this according to the natural position. So that is one sign. Another is that when you see expansion, it's just like the puffer fish suddenly becomes blown up. And that's because of the desmoplastic reaction inside it. When something is like, that shouldn't be like that. It's like there's something inside it. There's another sign. Depression. Depression is horrible. So whenever you see depression, be very careful. Even the small ones with depression has a high risk of submucosal cancers. When there is nothing on the surface, it's just bald. Suddenly something like had chewed on it. That is another sign. When it's irregular. So that means that there's like different speed of the growth. Then you need to be worried about submucosal cancers. Firmness is not what we see, but we estimate it because of our experience before. We see, okay, something that looks like this is actually firm. You have to touch it. Now, the next level then is that we use these different classifications to have our mental models. So here the Paris classification tells you if it's anything depressed anywhere in the body, that's bad. Something that's flat, that is also bad because you need to cut it in one piece if possible. And anything that's non-polypoid has a higher risk of higher dysplasia and submucosal cancer. The larger, more than one centimeter polyp is classified this way. And it gives you all of these different mental models to be thinking about how to approach it. We talk about the LSDG. And we immediately say low risk. We can do this. Again, depression, bad. I just want to share you with this one picture, last picture. Which is to say the small polyp, the diminutive polyp may have some depression. That is not depression. That labels is as a fairly sign. That is just a sign that is an adenoma. So thank you very much. Maybe I share with this about the biopsy because we often see this problem whereby the biopsy is actually negative. Where do you biopsy when something is thought to be cancer? Which is to say, look for the area that's bald. You think it as like the threads of our tires. When there's no threads, that's where you should be biopsying. So thank you so much.

Dr. Roy Satnick

Jerry Way Endowment

colonoscopy

polypectomy

deliberate practice

Paris classification system