colon. So I'd like to introduce and welcome to our stage our three speakers for this session, Dr. Tyler Berzin, Dr. Kevin Woods, and Dr. Shivangi Kothari. While they're coming up to the stage, I'll just remind you guys that there was a handout that you were given as you walked in on how to access the syllabus and slides. Those are available on the ASGE app or website through the ASGE website. So please go there if you haven't already. And now I'd like to welcome my co-director, Aki, who will introduce Dr. Tyler Berzin. Thank you. I'm honored today to introduce our Geriway Endowed Lecture Speaker, Dr. Tyler Berzin. The Geriway Endowment supports ASGE programs and activities focused on GI endoscopy, education, research, and mentoring. A past president of ASGE and recipient of the Rudolph Schindler Award, Dr. Berzin's many accomplishments include groundbreaking work in colonoscopy and polypectomy techniques and has become one of the world's most impactful teachers and mentors in this field. He has published several hundred articles in peer-reviewed journals and has written seven textbooks, including the major textbook on colonoscopy. He has lectured and participated in live endoscopy demonstrations on every continent. Dr. Berzin was also the co-founder and president of the New York Society for Gastrointestinal Endoscopy and the president of the World Endoscopy Organization. He is currently pioneering remote endoscopy education and teaching GI endoscopy techniques to colleagues in several African countries via virtual platform. It is a special delight to introduce my friend and colleague, Dr. Tyler Berzin. Tyler completed his internal medicine residency, followed by chief residency at Brigham and Women's Hospital in Boston. He completed his gastroenterology fellowship and advanced endoscopy fellowship at BIDMC, Harvard Medical School. He has authored almost 200 articles, book chapters, and his work has been featured in Gut, Lancet, New England Journal of Medicine, and Nature. He's a founding member of the ASGE and AI task force. He has also presented nationally and internationally on the role of AI and GI. Tyler is an associate professor of medicine at Harvard Medical School and the director of the advanced endoscopy fellowship training program at Beth Israel Deaconess Medical Center in Boston. Please join me in welcoming Tyler as he presents the Jerry Wei Endowed Lecture, Top 10 Things You Must Be Doing for High-Quality Colonoscopy. Welcome, Tyler. Well, first, I just want to say it's a particular pleasure to get the mic from Dr. Asambang. There's almost nothing better in one's career than to meet a rising star early on and then watch her rise into her leadership in the field and her impact. So I can't thank you enough for the introduction. So we've moved from esophagus to pancreas and now to colon, and there's really no better way to enter colonoscopy than by starting with honoring Dr. Jerry Wei as we've begun. Dr. Wei is really in many ways the father of modern colonoscopy in the United States. He's been a consummate innovator and teacher, and I think when it really comes down to it, and I saw Dr. Wei this morning, I think he's in the room, I hope that he can look around at the audience. There are over a thousand people signed up for this course, and there's not a single person in this room whose career has not been impacted by his work in the field. So I just want to acknowledge and be grateful for his impact for us. All right, so top 10 things we have to be doing for high-quality colonoscopy. As we look at this picture of Jerry, I would guess about 30 or 40 years ago, a lot has changed. We're not using eyepieces anymore. Most of us are using gloves, but otherwise, a lot of the key concepts around high-quality colonoscopy have been true then and are true now, and we will walk through them together. I'm going to try to give you a top 10 in 15 minutes or less, and I'll try to make a comment on what we all should be doing in 2024 for each item. So first, starting with a clean colon. A poor prep is not just an inconvenience, it's a missed opportunity. Nearly 50% of patients who have a poor prep do not end up returning for their colonoscopy, so this is a critical quality of care issue, not just an inconvenience for our schedules. How do we solve that? For the most part, the two key issues are split-dose prepping, which really should be our gold standard at this point. Optimal dietary recommendations remain a topic of controversy, and we may debate on the panel what is the right move. There is a movement towards low residue the day before, as opposed to clear liquids. We've not made that move at my medical center, but we're talking about it. More importantly, we need to educate our patients. Bowel prep instructions have to be clearly written at a sixth-grade level, in the patient's native language. I'll underline those last three words, and I will also add that if there's one thing you take away, nurse navigators or patient navigators improve bowel prep success rates. This has been the one change that we've made at our medical center in our GI division in the last few years that has led to the highest patient and physician satisfaction, having somebody else take over getting the preps right and taking pride in that as an important step in colon cancer screening. So, highly, highly recommend exploring that. Meticulous inspection. You know, successful colon cancer screening begins and ends with high-quality inspection. We often think about time as one of the core elements of inspection, but inspection quality is really a cross-product of time and technique and attention, and we need to try to optimize all of those things. For technique, I think the best things that we can do to optimize or to consider taking a second look in the right colon, ideally in retrograde, but a second look in anterograde helps as well with sessile lesion detection. Experimenting with mucosal exposure devices and just finding ways just to be meticulous and intentional, even though you have 10, 15 cases in a day, each one is a critical one for you. Adenoma detection rate gets a lot of the attention, but it may not be the most critical metric. There are discussions ongoing about whether other metrics, including sessile serrated lesion or sessile lesion detection, are going to be more important. Right now, practically, I can say that, but we all know it's really hard to report and get that data. It is going to become easier as we use AI tools and further integration in EHRs, so there will be a future where you know your sessile lesion detection rate, and this is something we're going to have to pay attention to. When we do find the polyp, we've got to remove it successfully. I know a lot of DDW is about going to presentations where somebody shows the largest polyp they've ever seen and how awesome it was that they removed it, and that is important, but what is more important is removing the much more common polyps correctly. Small polyps are far more common than large polyps. We've got to get the small polyps right. How do we get it right? Generally, using a cold snare on these polyps is the right way to do it. This video is going to show a standard technique for using a cold snare polypectomy. We want to use a thin wire snare with a stiff sheath. That's essentially the definition of how any cold snare is designed. We're aiming to keep the lumen inflated. This limits the submucosal tissue trapping as you try to close and go through, and then we'll try to push the snare tip down, snare sheath forward as you close, and then the goal is to take a surrounding normal tissue margin. Sometimes you'll see a little tuft of white tissue. That's called a cold snare protrusion. It's just sort of elastic submucosal tissue. It is harmless. You can let it be, and it's nothing to worry about. A couple of extra tips for removing small polyps completely. If you've removed a small polyp completely, you should generally be seeing a halo or Saturn sign or maybe a fried egg sign as evidence of a healthy tissue margin around the polyp after the cold snare. The second tip, especially if you're removing a slightly larger polyp, five, six, eight millimeters, is to use the water jet to inject and expand the mucosal defect. It not only slows the bleeding because it creates some tissue tamponade, but it also makes it much clearer if there's any residual polyp around the rim that you need to take care of. We will sometimes encounter large polyps, and we have to make the right call about managing those as well, and the right call involves inspecting, resecting, or potentially referring optimally. We have to pay attention to polyp morphology and surface pattern. I am well aware that there are a hundred different classification schemes, many of which are used very intermittently in the United States, and in general, most of us don't use any classification scheme reliably, but I would suggest becoming at least familiar with the Paris classification, and frankly, it may be sacrilege. I don't think it matters whether you remember the names of any of them. I think paying attention to the shape of a polyp, whether it's flat, slightly depressed, ulcerated, is way more important than whether you happen to remember what a 2B or 2C is. The NICE classification, on the other hand, I think is something that is truly worth knowing in 2024. It is the simplest, most straightforward, and practical NBI classification scheme, and you can get used to it by turning NBI on and looking for a sort of cerebroform pattern in an adenoma or interrupted or missing irregular surface blood vessels in a cancer. If you take one thing away from this lecture, my suggestion is that you print out a picture of the NICE classification in your endoscopy unit and just practice, and I think you will find in very short order that you have a new superpower with much higher accuracy and comfort than you might expect. The NBI is already built into the scope, and I think the error that we've made with older classification schemes is that they're too complex and sort of bulky, and the NICE classification really simplifies it down to something that is practical. When you get used to using the NICE classification, you can start making the right call for large adenomas. You can see that a NICE 2 polyp is clearly an adenoma. You can either prepare for EMR if you're planning to do it, or you can tattoo nearby the lesion because that's not the day you're going to do it, or you're not the person who's going to do it. It is okay to biopsy if you're really uncertain, mostly if you think there might be a cancer there, but if you think it's just an adenoma, generally I would ask that you avoid biopsies. Multiple biopsies, especially towards the center, can make advanced resection more difficult. And then if you see that it's a NICE type 3, a suspected cancer with these irregular patterns on the surface under NBI, that's the one that you can biopsy heavily if you'd like and go ahead and tattoo. I want to get back to the classification schemes because I think it's one of the biggest divides between what you hear and see at DDW and ACG and how we actually practice in real life. Again, most of us are not routinely using these, and I think part of it is because we're overwhelmed with the number and complexity of these tools, and I'm fearful that we're going to miss the polyp for the trees. Don't miss the forest for the trees. Yes, you should pay attention to morphology and shape. Yes, you should pay attention to surface pattern. But more important than memorizing the classification schemes is to recognize key patterns that are going to change your management, and that's central depression, interrupted surface vessels, etc. If you recognize those patterns correctly, that'll correctly guide your decision making and you'll be a pro. You have to become a tattoo artist. Number five, the best way to become a tattoo artist is to make sure you're tattooing away from and not under the polyp. You typically want to choose an area at least two or three centimeters away from the polyp. Tattoo under the polyp, again, makes advanced resection a little bit more difficult. There is controversy about whether we should be tattooing on both sides of the polyp, proximally and distally, or just distally. I am going to make the argument for the distal side. The argument for tattooing just distally is that if you are a surgeon and you get into the operating room and you know that Dr. Calderwood has tattooed on the proximal and distal side, but you only find one tattoo, you do not know where that tattoo is in relation to the tumor. But if you know that she has just injected distally and you find a tattoo, you know where the polyp is. In general, distal tattoo is preferred. You can tattoo distally in a few different areas at 12 o'clock and 6 o'clock, but it's preferred. Talk to your colorectal surgeons. Make sure you have a plan with them. But most colorectal surgeons I've pulled prefer distal only. You also want to actually target the submucosa. It's very easy to get peritoneal injections, and we all know it's very easy to spray all over the lumen and be very unhappy with the appearance of things. If you want to be on the meticulous side of tattoo injection, a really satisfying approach is to use the saline bleb method. And what that means is that you'll prime the needle just with saline. You'll find the submucosal space with saline. It's nice and clean. And the second you find the submucosal space, you move over to the ink and it creates the most beautiful, clean bleb you've ever seen. It is just about as efficient and sometimes more efficient than spraying ink all over the place and a much, much cleaner way of doing tattoos. We have to update our surveillance intervals. Many of us, myself included, play fast and loose a little bit with the surveillance intervals that we recommend after screening colonoscopy, depending on polyps that we've found. If you are recommending the same surveillance intervals that you did during the George Bush administration, it is time to make an update. And it is honestly hard to do that when you've been practicing. I've been practicing for 12 years. I have a knee jerk that if I remove an adenoma, I want to give them a five-year follow-up. And we have to start moving towards lengthening those intervals. Part of it is an acknowledgement to the fact that we are doing better protecting our patients. Our technology is better. Our techniques are better. The colonoscopy is more protective now than it was 5, 10, 20 years ago. The other sort of paradox that we're going to have to be prepared for, and we haven't tackled it yet as a field, is that high-quality endoscopists detect more polyps, but their patients may actually be appropriate for longer surveillance intervals. If you're a really high polyp detector and you've detected five polyps, you've probably protected your patient better than the person down the road who has an ADR of 10%. And yet, the guidelines create some tension there. So at some point in the future, there may be some ongoing nuance about high and low polyp detectors, and that's We have to modernize our anticoagulation management. For screening colonoscopy, anticoagulation should be continued for patients with moderate and high thromboembolism risk. My approach for anticoagulated patients is you can remove most polyps less than a centimeter with a cold snare. You can clip if you like. If you see immediate bleeding, there's virtually no delayed bleeding with cold snares. And then for polyps that are greater than a centimeter, you can make an intervention with a cold snare. If you see immediate bleeding, you can make an individualized decision. I tend to remove them and clip and manage. It's also totally fine not to and get the patient off anticoagulation and come back if they can, but most small polyps can be removed on anticoagulation. Number eight, you have to document your excellent care. We have to record high quality images of all landmarks in pathology. Photo documentation helps your patients understand what you saw and did during the colonoscopy. Photographs showing sacral intubation and landmarks can also be useful as part of a medical legal defense if you're ever stuck in that scenario. Additionally, clear photographs of large polyps may help subsequent planning for advanced resection. Nine, we have to actually take care of ourselves. If you want to be doing high quality colonoscopy in five to 10 years, you have to be alive and healthy and practicing as a gastroenterologist. The system that we live in incentivizes us to take really, really poor care of ourselves. We got used to that in medical school. We got used to that in residency. I think we have to take some ownership of our lives and our life balance and our exercise and our health, not just for ourselves, but also for our patients. In our endoscopy suites, it means a neutral monitor position, a use of a neutral bed height, maybe anti-fatigue mats. I have seen ASCs spend a day with a physical therapist or ergonomics expert who comes into their unit and helps the nurses, techs, and physicians try to optimize the environment. I would bet you that financially that is an absolutely worthwhile investment to make sure everybody is working and healthy. Ultimately, you have to recognize that your body and mind are your most valuable assets for a productive and satisfying career. Finally, we have to embrace innovation and change. If you walk around any of the DDW fora today, tomorrow, you will recognize that there is some healthy competition for colon cancer screening tools. Colonoscopy is not the only kid on the block. How do we respond to these potential threats to colonoscopy? The Nordic trial, Cologuard. I think, number one, we have to remember that colonoscopy became a centerpiece of GI practice because GI leaders and innovators embraced change and adopted new technologies for the benefit of our patients. That is what Dr. Wei did years and years ago. Number two, I think we have to encourage our practices to try new things, new devices, new technologies, new approaches to ensure we are offering better cancer prevention in 2024 than ever before. That might mean distal caps, it might mean AI, it might mean hiring a prep navigator, text-based reminders, you name it, but doing something to innovate and get better. And three, I think we have to recognize that GI physicians are the colorectal cancer screening experts. I've noticed in Boston that after peri-pandemic and around the time of the pandemic, all of a sudden, the locus of decision-making for colon cancer screening has often moved towards primary care doctors. That's driven partially by the pandemic, partially by the Super Bowl Cologuard commercials, lots of different pressures. I think we have to ask the question around whether GI practices can create colorectal cancer screening hubs that really own the whole process so we can be the decision-makers to make sure each patient gets the right decision. One way or the other, I think with all of the competition around colon cancer screening, we cannot bury our heads in the sand. We have to embrace innovation, and in times of change, learners inherit the earth. Thanks very much.

Dr. Tyler Berzin

Colonoscopy

Colon preparation

Polyp removal techniques

Colorectal cancer screening