It is now my pleasure to introduce Dr. Kevin Woods. He is the Chief of Gastroenterology, Endoscopy, and Nutrition at City of Hope Atlanta and the Therapeutic Endoscopy and Associates, and he will be presenting on Preventing the Post-Polypectomy Bleed. Thank you again for the opportunity to speak today. As we just heard a great conversation about colonoscopy, I have no disclosures as it relates to this presentation. We all have now heard how we need to approach these lesions, but of course, the more we do endoscopy on the colon, we can tell that most of these lesions in the mucosa can be seen almost anywhere in the GI tract. Indications for removal span not just the colon, but also the stomach and hyperplastic polyps, barrets with BE-associated neoplasia, and also duodenal adenomas, which we come into contact more regularly now because we have much better scopes that can see these changes. In all cases of resection, if a snare polypectomy or endoscopic mucosal resection, we should be thinking about and monitoring our patients for post-procedure-related complications. Just a reminder, as in 2020 ASG guidelines, this has been placed for your review afterwards, but this is a really, really wonderful guideline that really walks us through everything we just heard in the last talk, just about how we're thinking about how we resect these lesions. What's safe based upon size to use cold versus hot? And then obviously, when we get to larger polyps, when do we start thinking about using electrocautery and other techniques, which we'll talk about a little bit later in the talk. But one of the considerations prior to removing a polyp anywhere in the GI tract, if that's in the stomach esophagus or in the colon, when we think about snare polypectomy and EMR, what should we be thinking about? So here's a video essentially showing a duodenum opposite on the lateral wall in the second portion of a flat adenoma, as you can see here. I'm going to go ahead and lift this polyp, given that it's flat, using a 3% saline solution along with 3 mLs of methylene blue and about a 500 cc bag to give us a really nice look at the submucosa. And using a snare, my preferred snare in this case is a stiff, double-braided 20 mm snare, which you can see, nicely laying over the top of that polyp to make sure that we don't grab too much tissue, and also bringing to the base of that polyp the snare to make sure that we can actually grasp, and then with electrocautery, using cut, resecting that polyp. As you can see here, we were lucky, I always pray when I do that that I don't see blood or a hole, but of course, at this point, we're going to close that with a hemoclip. So as many times if you've done this, as all of us have approached, you will run into problems. So what are considerations? Although we think about it as intuitive, but we really need to be thinking about all the things that we heard in the last lecture. Again, quality of the bowel preparation if we're doing colonoscopy. It's very difficult to resect or have a complete resection if you have stool in the way. This also can be a problem for us when we have GLP-1s down that are not alignable to clear the stomach. So again, not having a great feel to see these small polyps is a problem. In addition, where's that located target lesion? In that video I just showed you, we started off at the 3 o'clock position because we always want to work in that 6 o'clock position as is preferred and gives us much more flexibility. Thinking about other areas of the GI tract that always leads us to hold our breath. The gastric fundus is so, so very thin. So whenever we're moving something in retroflexion, just know it's easy to perforate there. The duodenum, of course, the ileocecal valve and the cecum. Stability of your endoscopic position always should be thought about. And also, where's your endoscopic skill and where's your tech and also the devices on your unit? Do you have clips available? Do you have different clips? Do you have larger clips, smaller clips, rotatable clips? Do you have the ability to suture? All these things should be going in the back of your mind as you prepare to do a resection. The rate of overall complications for polypectomy and also resection are actually approximately 10%, some being minor and major. But post-polypectomy, coagulation syndrome, of course, is one. Incomplete resection of a target lesion, which either through piecemeal resection, of course the whole goal is to get any of those lesions out en bloc. And depending on your technique and also your experience, that may be a challenge for some. But then, of course, perforation is always something we're thinking about, but it's really rare. As we start to walk into the title of this talk, it's looking at the post-polypectomy bleeding, which in one series is about 4.3 per 1,000 in occurrence. This next video walks us into the esophagus of a patient that had BE associated neoplasia. Obviously, we have resected the mucosa using a band ligation technique. But we can see here an active bleed. Intra-procedurally, we love this because we can find that source and we can stop it. We're not going to get called in the middle of the night, but using this cap for those that do EMR, this is a nice way to stop and put pressure on the tissue, wash it away. In real time, you'll find the bleeding source, as you see there at 6 o'clock. And then with scleric artery, with the tip, you can apply carotid and stop it. This is probably the best example of when you feel great, knowing that you may not get But how do you know that this patient is not going to bleed later? As we now move into other aspects of care with patients, we have to think about, you know, how many times will this happen? And especially in the colon, what are the risk factors that actually put these patients at risk? So again, polyp size in the right colon greater than 1 centimeter has been shown to increase risk and the left colon greater than 2 centimeters. And of course, anything that's in the cecum or in the ileocecal valve tends to have higher rates of complication. Of course, if you have a much larger polyp and you use piecemeal resection, that will lead itself to many more complications. We're not going to focus on the intra-procedural like I showed with that EMR, but we're not going to really just look at the late post polypectomy bleeding. And that's always defined as when you have stopped your case, when you have actually removed the scope and then the patient is going home. So are there techniques that decrease the risk of post polypectomy bleeding? And of course, the question that we always think about is cold versus hot. For a long time, as I was trained, I always thought about using electrocautery. And of course, as we heard in a prior talk and in our guidelines, anything less than 10 millimeters should be something that we can take care of without using electrocautery. In this video, this is in a colon. I'm in a really great prep. This polyp is in a 6 o'clock position using, again, a snare at the base, pressing into that polyp. And now with cut, no cautery, we can see that we have a complete resection and just a little bit of bleeding. But at the end of this, the real take-home points is it's really based upon size and also the Paris classification of a polyp. If you have a pedunculated polyp, the ASGE guidelines and the literature supports that a hot-snare polypectomy should be reserved for those polyps that are greater than 10 millimeters. And of course, any large sessile polyps that require endoscopic mucosal resection should be resected, in many cases with cautery, although many of my colleagues in the room, we won't talk about it here, but could also use water immersion as another tool to remove large end-block resections in the colon without cautery. But with that said, again, cold-snare polypectomy should be reserved for those cases that have less than 10-millimeter-sized polyps. But in many ways, we think about it as not only just the polyp, but it's also you as an endoscopist and also the patient. As we just heard, and I think that we're starting to see so many antiplatelet and anti-antibiotic medications with our patients, and it always puts us in a really, really hard position of how long do we wait? Is it five or seven days for Plavix? If that patient does need an antiplatelet medication and also anti-thrombotic medication, how when you have to be put in that position to remove the polyp, when do you know when it's safe? That's never an easy question, but something we should think about. What's the size of the lesion? What type of histology is it? Is it spreading T, SPP, or is it just a tubeless villous adenoma that you can see a nice base with AI tools or even with optical and endomicroscopy? Whatever tool you're using, you really need to continue to think about that. And then lastly, do you have on your unit things like an endoloop or a clip or even ability to suture? So as we look more into this question, Zhang et al. looked at the question of what are the risk factors for delayed colon resection, polypectomy, bleeding, and they did a meta-analysis, 15 articles, basically looking at 24,000 subjects. And what they found was a very, very low rate, less than 1% in this case, and a very, very nice confidence interval showing a large international cohort of studies that were included. And this study was only one American study, but we see from China, Korea, and also Japan, really large groups of patients that were included. And this was basically looking at a delayed risk. And what we'll find is that in those three areas of the patient, the polyp, and also the presentation is that patient-related factors, anticoagulation, as we talked about, very small, but significant finding of hypertension. Lastly, polyp size, of course, the larger the polyp, the more likely that you will get into a situation of bleeding. And then lastly, resection method. The larger the polyp, the more likely you're going to use EMR for those that do that and also apply electrocautery. So again, the things that we can intuitively think about, but the data definitely does support it. So to clip or not clip? We all think about this when we made a nice resection, and it looks so wonderful to see the submucosa. Do you leave it alone, or do you clip it? Does prophylactic clipping of polypectomy sites decrease bleeding? And again, in our toolbox, we have all these nice new technologies and techniques, from endoluce to hemoclip placement, epinephrine injection, cautery, APC, ovidoscope clips, TTS, and suturing. Which one do you use? And lastly, does it, in fact, actually decrease your risk if you prophylactically close? I want to highlight two studies, meta-analysis, that really did a wonderful job on the left. Gawande, in 2021, looked at, as you can see, all the randomized controlled trials that basically looked at this question on the right. In 2016, you'll see all the way back from 2002 to 2016, this is about 17 years of looking at this question, which was robustly evaluated, demonstrating in these series that cold polypectomy or hot polypectomy or EMR, whenever you close those, they actually did not really show a large effect on polyp sizes less than 20 millimeters. So if you have a very small polyp and you see a little bit of bleeding, I suggest you wait, wash, and it probably will stop, like all bleeding stops at some point. But when you then move into much larger polyps, the question is, does that same data support it? And then unfortunately, we could guess that that's not the case. So a really great article, again, showing that hemoclip placement and prevention of delayed bleeding in very, very large, say, greater than 20 millimeter polyps actually showed prophylactic clipping is effective in preventing a post-polypectomy bleeding in those polyps that are greater than 20. And so to clip not to clip, but what if you can suture? Should that be something that we now add? In closing, here's the last video I'll show you. I'm in retroflexion in the colon, as you can see, a very large, greater than 3 centimeter tubal villus adenomas resected. After the lift, you can see it nicely flattens, and we're now using the through-the-scope suturing. That anchor, which has now been placed on the right lower edge of that resection site, bringing it over to actually do a continuous closure. As we move through this, we're now starting to bring that defect together, putting the center over the top, and the bottom right, we'll see that this has now brought that mucosectomy site closed. You can see on the left and right, it's not actually totally closed, and in this case because of retroflexion, it was hard. I didn't want to lose that position, but I pulled back and then placed two clips. And what you'll see here is a complete closure of that mucosectomy site. So as we think about all the tools that we have when we start to look at these really, really large polyps, again, in the cecum by the ileocecal valve, it is possible with a great prep, great positioning, and also with good technical skill to actually close it. And so to some of our colleagues in the room, we thank you for the work you guys have done. This is a new device that is out for over the last two years, and this is basically showing a suture-based deep submucosal intramuscular enhanced fixation through a standard endoscope and colonoscope. So for those that don't suture and have not used traditional double-channel suturing device, of course there is a single-channel device that is out there. When you're on the right side of the colon, it makes it very, very difficult to get that device there. But what you'll see here, as you just saw, I just showed in the video, this really adds up to four points continuously per suture to close large defects. Really just want to highlight in this study, it was a retrospective multi-center study in nine centers using the X-TAC Helix system. What we found is there were many indications in this study that were looked at, but really what was the take-home for this talk is that both technical and clinical outcomes had a 100% success rate in the sense of closing those defects for polypectomies. That is really something that I found now to be much easier to use than firing off six clips. One for timing is actually a lot easier and is a lot simpler, but it also allows for you not to have to lose position. So for those that have used it, we'd love to see more studies on this. But in summary, I hope that in this 15-minute talk, you basically heard and seen what the risk factors are. Male sex, hypertension, anticoagulation, polyps size greater than 10, and polyps on the right colon. And especially when we used endoscopic methods like ESD and also EMR to remove these polyps puts us at risk. Hot snare versus cold snare, I think the jury has rendered as verdict, anything that's less than 10 millimeters, you should try to attempt to remove that with a cold snare. And prophylactic clipping does not really show benefit in those smaller lesions that are removed. And lastly, through the scope suturing, again, safe, feasible, and also has 100% technical clinical success rates for closures, especially when you get to a lesion that I saw that is greater than 20 millimeters. But thank you so much. I want to thank my team and City of Hope and also Therapeutic GI, and thanks so much.

post-polypectomy bleeding

lesion removal

GI tract

snare polypectomy

endoscopic mucosal resection