Thanks, Audrey, and good morning everyone. So I was asked to present some tips on better basic colonoscopy and I'll start with safety. So I think we need to approach colonoscopy with the attitude, the determination and the skill that we can perform thousands and thousands of routine colonoscopies without an insertion related perforation. And one of the key rules for that is don't push against fixed resistance. So this is the feeling that as you're pushing the scope in, the colon just won't give way with you anymore. I think by far and away, the most common reason for this is that there's just a large loop in the scope and the colon won't take any more stretching. True fixed resistance where the colon is socked in by adhesions. This is usually somebody who's had a lot of pelvic surgery, often radiation, I think is very rare. So if you encounter that, you need to back off, consider switching to a skinnier scope, which may be able to overcome it, fill the colon with water. But most of the time, the way to get around this is just use good technique, back away, but you can't violate that rule of continuing to push because even a normal colon could potentially break open. Another key way to avoid insertion related perforation is to convert all difficult sigmoid colons to water. And the purpose of this is to avoid barotrauma. So these are the rules of barotrauma. Most patients who have a bad sigmoid will not suffer barotrauma. On the other hand, barotrauma perforations only occur in people with bad sigmoids. You have to anticipate the risk of barotrauma based on difficult sigmoid colon anatomy and convert to water. And remember that these are often the worst perforations that we encounter because the prep is often dirty above the sigmoid narrowing, the patient had a hard time getting cleaned out and they can develop compartment syndromes. So on the left, the normal situation when we're going through the sigmoid insufflating gas, gas can escape back around the scope and come out the anus. But on the right in a very tight sigmoid as you're insufflating gas, it may not be able to escape. And if the ileocecal valve is competent, you get this closed loop between the scope and the valve, the colon gets distended and it can perforate. And by the time you reach the proximal colon, it's already happened. It's too late. So you have to anticipate patients that are at risk. And every time, even if you're using CO2, convert to water. So there's the situation, the bad one on the left. And we prevent this by using water as we encounter the difficult sigmoid. Tip number two, take care of people's spleens. We think there's now, based on the US national data, splenic injury about one in every 6,000 colonoscopies. Women, I think especially thin women are at particular risk. And I would say the best rule to follow is that if you have the scope tip up proximal to the splenic flexure, and especially if you have a difficult loop, multiple loops in the scope. As you're removing those, be very gentle. Don't do anything that's going to pull down on that ligament or twist that ligament. So again, avoidance is key. Tip number three, employ the basics of high level detection. So this means split or same day bowel preparation in everyone. Low volume when possible. Low volume preps are as good as high volume preps in most patients. And we know that they're better tolerated and our patients complain more about the prep than anything else. So why not try to improve their satisfaction? High definition colonoscopes measure and report ADR and then use a compulsive examination. The components of that are looking behind folds, achieving adequate distention and cleaning up. Tip number four, examine the right colon and the rectum twice. We now see fairly regularly a big series of interval cancers come out. This is another one from just a couple of weeks ago, 762 interval cancers. Still the most common location is the cecum and ascending combined, but almost a quarter of them, and this has been seen repeatedly, are in the rectum. If you could start that video. So our good examination technique consists of cleaning everything up, cleaning it up by washing meticulously. Then the work of withdrawal is this process of going back multiple times, looking on the proximal sides of every household fold. We want to keep a three-dimensional map of the shape of the colon. Keep track of what we've looked at and what we haven't, and make sure that we're probing the proximal side of every fold. Getting adequately distended, which is easy to do in the right colon. So in the right colon, we're going to do an initial examination from the appendiceal orifice all the way back to the hepatic flexure, and then we're going to reinsert the scope down to the cecum. Looking at the cecum again in the forward view, because if you go into retro, you're not going to see it in retro, and a lot is missed in the cecum. So look at the cecum again in the forward view, and then decide if you want to do the ascending second examination in retroflexion or in the forward view. The data says that both of them are good. I like to do retroflexion, especially if the right colon is straight, it's got nice luminal caliber, it's an easy, it's a very safe maneuver. We're going to pull the scope back all the way to the hepatic flexure in retroflexion, and then unwind and continue the examination. If you could start the video, please. So in the rectum, same deal. These big valves in the rectum can hide really significant lesions. They can hide a significant amount of mucosal surface. So we come back in the forward view all the way to the dentate line, and then go into retroflexion. Again, that perforation can occur during retroflexion. I think the biggest problem is when the scope escapes up into the proximal rectum. So keep the scope in the distal rectum. Once you get into retroflexion, rotate the scope a full 360 degrees, and then go back to the rectosigmoid junction and check the proximal sides of those valves one more time. Again, almost a quarter of our interval cancers are occurring in the rectum. Start the video, please. Okay, left colon examination. For most of us examining the patient in the left lateral decubitus position, the problem is keeping the left colon distended. So we want to do an aggressive examination. I think using CO2 helps because we're not as worried about post-procedural discomfort when we're using CO2. We can pump gas like crazy. You can rotate the patient out of the left lateral decubitus position, but most of us don't like to do that in deeply sedated patients. You can fill the left colon with water. I will tell you what we do most often is we have the tech take a hold of patient's rear end and squeeze it together. We call that cracoid pressure or the tush squish, and it just keeps gas from coming out of the rectum so that you keep the left colon distended. But you see that this is an aggressive examination. We're going back and forth across the haustral folds. You want to feel like you're in command of the colon. You're in control of the colon, and you're determined to see every square centimeter of the mucosal surface. Tip number six, measure the SSL detection rate or some measure of serrated detection. Our current measure of the quality of inspection, the adenoma detection rate, does not include sessile serrated lesions. And we've seen now a couple of studies, including one from Evelyn, that doctors who have high ADRs but low SSLDRs do not prevent colon cancer as well as people who are high at both. So we're entering an era where we need to start to measure them. And you can see here, of course, these are very subtle lesions as we go from top to bottom, left to right, progressively more subtle. And we know that we miss these more, if you could start both of those videos, please. Then we do conventional adenomas. So on the left is an SSL, and on the right is another SSL. And you can see that I've got the AI on here. And it's not sending a signal for either one of these lesions. I've got a huge collection of these. There's an abstract, a meta-analysis at this meeting that suggests that AI does not improve the detection of SSLs. So I think we need our AI programs to be better trained in the detection of SSLs, but we need to measure how good we are. That's the key first step. A lot of things have been shown to improve SSL detection using NBI, LCI. If you're an Olympus or a Fuji user, you have one of those options, spraying dilute acetic acid on the colon. The key thing is to have a very good eye for these lesions, and to measure to find out if you're good at detection. Next slide, please. Okay, tip number seven, evaluate a mucosal exposure device and a highlighting technique for yourself. The best studied mucosal exposure device is the Endocuff Vision, about a 7% average gain in ADR. It adds to detection by CAD-E in a recent randomized controlled trial, and it can shorten withdrawal time without impairing detection. And a highlighting technique, combining that with a highlighting technique like AI plus electronic chromoendoscopy, or maybe both. AI works beautifully in randomized controlled trials and tandem studies. We've seen a couple of US real world assessments where it didn't work. And I think just like colonoscopy is operator dependent, the benefits of ancillary devices are often operator dependent. And I would encourage everybody to test these out, make some measurements yourself and find out if they improve your colonoscopy performance. Tip number eight, abandon cold forceps for polyps less than or equal to 10 millimeters. We know now that cold resection will take care of everything that's 10 millimeters and smaller. Even the pedunculated lesions can be safely removed if they're small by cold sneer resection. Cold forceps are still very commonly in use. They are effective for one to three millimeter polyps, but they're not for four millimeter and larger polyps. So if you start off the removal of some tiny lesion with a cold forceps, and now the patient also has a larger lesion. Now you've got to get a second instrument out, more cost, more plastic waste. And we just heard some of the problems that are associated with that. Start the video, please. So it's important to perfect our cold sneering technique. I think the basics of cold sneering can be basically brought down to three things. One, are you rotating the lesion into the five or six o'clock position? Second, can you maintain the proper working distance? Not too close, not too far away. And third, do you place the snare accurately, which means that you're getting a margin of normal tissue around the entire polyp. And this is something, start the video, please, that needs to be practiced. Here's a lesion over on the left. We're going to rotate this lesion again down into the five or six o'clock position. Notice that we don't get too far away, we don't get too close to it. And we place the snare very accurately to get that rim of normal mucosa that is around the lesion. So if you struggle with this, I think this is an area that needs more practice and can, with practice, you can get to the point where you don't need to use cold forceps at all. Tip number nine, avoid clipping cold resection sites. So the beauty of cold resection is that the risk of delayed bleeding is extremely low. We just saw this in a huge randomized controlled trial, proof that the risk of bleeding after resection by cold snare is lower than hot snare. So that's the beauty of it. But I think there's a tendency for sometimes to still clip sites when there's immediate bleeding. When you get this kind of thing, and you're uncomfortable with it, first thing is blast the site with the water jet so that you fill up the submucosa. If that doesn't work, take the end of the scope and just push on it, just like you're putting your finger on it. Or you can put the snare back out, re-grab the site, and hold it for a few seconds. But only in rare instances does a cold resection site require prophylactic clipping. My final tip is that when you are resecting larger pedunculated lesions, where you are often going to choose a hot snare, don't put anything like a loop or clips or anything on the stalk. Your primary consideration should be the possibility that there's cancer in the polyp. These big pedunculated polyps, about 5% to 10% of them have cancer. And about a third of the time, that cancer is invasive into the stalk. If on the left you put a loop on there, then that's going to force you to move the snare a centimeter or more up the stalk toward the head. And now you're risking cutting through the cancer. So here are a couple of photomicrographs of pedunculated polyps with cancer invading the stalk. And you can just see those lines. The closer you move up to the head, the greater the chance that you're going to cut across the cancer. And then the patient's going to require surgical resection, if you could start that video. So I think leave all that stuff off, get your snare over, get it down low on the stalk and use forced coagulation current. If you use forced coagulation current, you'll almost never see immediate hemorrhage. You don't need a loop on there because it's not going to hemorrhage. It's almost no reason to use cutting current or blended current in the resection of a pedunculated polyp. And then you get that nice long stalk. If you want, you can put a clip on the site after you've performed the transection. So in summary, don't push against fixed resistance, use water insertion in difficult sigmoids, keep the spleen safe, employ compulsive basic examination technique, examine the right colon twice and the rectum twice. Keep the left colon distended, figure out a way to do that. Measure SSL detection, evaluate a mucosal resection tool and a highlighting technique in your practice, in your performance. Remove everything 10 millimeters and smaller with a cold snare, abandon cold forceps, avoid clipping cold resection sites, except in the most persistent bleeding. And when you are removing large pedunculated polyps, move low on the stock, maximize the opportunity for a best oncologic outcome if cancer is present. Thank you.

safety

insertion-related perforations

sigmoid colons

high-level detection techniques

oncologic outcomes