All right, let's do some video quiz. So, this is a patient who is about a 35-year-old woman, and she had a history of vesicoureteral reflux as a small girl, and she had chronic kidney infections from this. So, any thoughts about this? This is a ureterosigmoidostomy orifice, and I've only got a few patients that have this. I did see a malpractice case. You can see this have a very polypoid appearance to it. That's the opening of the ureter. This bulge right over here is from where the ureter is embedded in the sigmoid colon. This operation was associated with an increased risk of cancer around the sites and then distal to this down to the anus. It's usually recommended that you biopsy, but you don't want to disrupt this. The malpractice case that I saw was where a physician did not get the history of these ureterosigmoidostomy implants. You don't see this very much anymore. The operation is really not done anymore, but some of these patients are still around, and I think it's a reason. People often say, like, what do you get? What do you talk about with patients? I always say, how's your health? How's your heart, lungs, liver, kidneys? Are you on blood thinners? Do you have a family history of colon cancer? What are your previous surgeries? Most of the time, the surgery history is not very relevant, but this is a rare case where it is. If you don't know the history, just by looking at it, it's impossible to say what it is. It almost looks like a small diverticulum. You can't really tell. I think the polyploid form, you don't want to remove the polyp. This is a patient who has had an endoscopic mucosal resection six months earlier, and they're having their first follow-up. This is the scar, and the question is, what is this stuff? I hope that you recognize this as CLIP artifact. Anytime you see a lot of erythema and white light with ulceration on it, your thought should be granulation tissue. This is granulation tissue. This is a site where some CLIPs were present, and they just recently have become displaced. This is what this looks like when the CLIP is still on. You can see that there's a lot of erythema. This is actually what I call mature CLIP artifact or type 3. This is ulceration. A lot of times, the pits on the granulation tissue on the scar itself are quite large compared to the normal pits, but they don't have the elongated. You can see those big circular pits there where the inflammation is. We call this type 1 CLIP artifact where the CLIP is still on. That's pretty obvious. Here's another example of this where there's very little inflammation. A lot of times, you see inflammation. Here's the scar along here from the EMR. If you use CLIPs to close sites, it's important to be able to distinguish the different types of CLIP artifact. This is, I think, pretty exaggerated mature CLIP artifact. At one point, all of these mounds presumably look like granulation tissue. Then as the CLIP fell off, and then the inflammation subsides, and you're left with these mounds of tissue. You can distinguish that this is normal and not residual polyp because the pits are fundamentally normal. They may look bigger than the pits on the normal mucosa, especially while the inflammation is subsiding. Eventually, they'll get down to normal pit size. The key thing is the pits are still round. This is just all CLIP artifact. It's very important to be able to recognize it so that you don't unnecessarily start. If you're going to biopsy the scar, and that's a whole different topic. I don't know, Ahmed, how you feel about that, but there's a literature that's developing that says we don't need to biopsy scars. I'm probably as much to blame for that as we published years ago. You could biopsy scars, and sometimes you would get polyp tissue visible histologically. When that was present, there was about a 25% risk of a late recurrence. Whereas if there was no polyp tissue in the scar, then the risk of a late recurrence was like 2%. I think examining the scar is most important, but as your study showed, that invisible residual or recurrence. I do biopsy the scar. Maybe in the last five years, I've had one or two occasions where I was not suspecting an adenoma, and it was reported as there was some recurrence. Yeah, well, we've had calls to stop doing it. I think it's not resolved yet. This is retroflexion. I've published before that retroflexion almost never yields additional adenomas in the rectum. It does in the right colon. I personally think retroflexion in the right colon is more valuable than it is in the rectum, but you do see a lot of other stuff. The question is, what is this thing? It's got a fairly characteristic appearance. We're looking at it here in blue light. It's just above the dentate line. You can see these below the dentate line or above the dentate line. I hope you're all thinking that this is condyloma. We're looking here with the near focus on, and you can see these very thin, lacy blood vessels. I think they're smaller, and they're sort of in the center of the white areas. That's characteristic of condyloma. This patient needs treatment for condyloma. Here's another example of this. Obviously, you want to, in every colonoscopy, inspect the perianal skin before you put the scope in so that you pick up the occasional condyloma, occasional squamous cell cancer. You can see that very thin pattern of vessels with a kind of thick, white surrounding it. It's just kind of the reverse pattern that you get with a tubular adenoma. Condylomas are what that is. This, I think, is an important one. This is pretty common. I get a referral, I would say average once a year, to remove a polyp that's in a diverticulum in the sigmoid colon. Sometimes I can tell just by looking at the picture that it's actually granulation tissue. We described this probably, I don't know, 20, 25 years ago, that about one in every 130 or 140 colonoscopies, we would see one of these. It appears as a polyp, it's in a tick. Sometimes a patient has a history of diverticulitis, and sometimes they don't. When you look at the surface of the lesion, it has ulceration on it, and it's got some blood vessels on it, but really it just looks like granulation tissue. I think it's an important thing to recognize. Perfectly safe to biopsy it. We usually do biopsy it to prove that it's granulation tissue and just eliminate the concern about it. I've never seen biopsy of it cause a complication, but granulation tissue in a tick. You run into that sometimes, Amit? Uncommonly, because maybe I'm missing it, but yeah, a couple of times I've seen it. Actually, the problem I have with NBI and granulation tissue, sometimes it just starts showing these abnormal patterns that you almost can imagine that they're nice type too. You have to be very careful with that and stop smearing these. Yeah, yeah. Granulation tissue, I think, is a very common thing. This is retroflexion in the rectum. I guess the question here is, what is this mound of tissue and why is it red and look inflamed? This is also a very common finding, but this is an internal hemorrhoid that has been prolapsing. The minimal prolapse change is typically that you see erythema, but a lot of times you'll see ulceration. Because it's an internal hemorrhoid, a lot of that hemorrhoidal bulk is above the dentate line. You can see the dentate line there, potentially a candidate, I think, for hemorrhoidal banding. Here is obviously an anastomosis. We're going to develop a theme here around granulation tissue. Again, this is a white exudate on this little mound. This is a small mound of granulation tissue, nothing else. You can see this around a variety of sorts of inflammation. We've seen it now as part of CLIP artifact. You'll see it on the anastomosis. You can see granulation tissue, as we said, in a diverticulum. I do think when it's in a diverticulum, it represents previous diverticulitis. Notice again that when there's inflammation that the pits are often quite enlarged, but they still have this kind of very circular pattern for the most part, really no suggestion of neoplasia. This is a little bit different one because this is a patient, I will tell you, that has a number of polyps. They look like granulation tissue, really. They're ulcerated on the surface. If this was a patient with inflammatory bowel disease, it's not. I would call these inflammatory pseudopolyps. Histologically, these are a little bit different. Any thoughts about this, Amit? Obviously, inflammatory polyps, sometimes like in young patients, juvenile polyposis, I guess. Yeah, exactly. This is juvenile polyposis. I think it's useful to remember that in juvenile polyposis, the polyps often have basically inflammatory characteristics. The reason we take them out is that occasionally when they are quite large, they will develop some adenomatous transformation. That is the change that we think can eventually lead to cancer, causes the colon cancer risk in juvenile polyposis. I follow a number of these patients. I take out way, way, way many more polyps that are just simple inflammatory polyps or juvenile polyps than are actually polyps with adenomatous transformation. Here we are in the right colon of a patient. We saw a lesion look like an adenoma. We see one lesion here. It looks like a small adenoma. It has a type 2 pattern on it. This is a lesion that is a little bit, got some adenomatous change here and some serrated change over here that we're sort of washing down. This is all in the right colon. This is a patient who's referred for me for a resection of one lesion. There's a lot of synchronous disease in patients referred with large polyps. Here's another one. What are you thinking at this stage, Amit, about this kind of presentation? I mean, this is serrated polyposis, right? Multiple, flat. Then one of them, a couple of them, I'm a little concerned with this nodule that has to be examined. Is there a dysplasia there? This is a dysplastic element right here. The actual border of the lesion is out here. I think actually, this is actually an adenoma. I think when you have SPS, and this is another one that's dysplastic, that's a dysplastic focus. The actual borders of the lesion are, it's probably two or three centimeters. There's another one with a focus of dysplasia. You'll see the dysplastic element. Here's the dysplastic element, and here's the rest of the serrated lesion. This patient has multiple SSLs with cytological dysplasia. Any dysplasia in an SSL is an advanced lesion. It doesn't matter whether it's low-grade or high-grade. I see lots of pathologists will send a report back that says SSL without high-grade dysplasia. I feel like, well, did it have low-grade dysplasia? Because they're supposed to be reported as SSL with cytological dysplasia or SSL without cytological dysplasia. Any cytological dysplasia in an SSL is an advanced lesion. Here's one that's a little bit more exaggerated. This is the dysplastic element. That's all nice type two. If you look over to the right, you can see a narrow band. Those are the big open pits I was talking about. We sometimes talk about the WASP criteria to differentiate a hyperplastic pilot from an SSL. One of those is these big, large open pits. This is an SSL with a great big focus of cytological dysplasia in it. I did remove this with electrocautery because that's one of the biggest foci of cytological dysplasia that you'll see in an SSL. Most often when you see them, they're just a little tiny nubbin like those ones we saw in the previous case, but that's a pretty concerning lesion. Hang on, Klaus. Hey, Klaus, I'm teaching an ASG course. Can I talk to you later? Okay. Okay, thanks. I apologize. My son called me earlier and I got to get my phone turned off here. I just want to show an angio-dysplasia and just ask, Amit, when we see these and a patient has no symptoms, I leave them alone. I see them each time. Yeah. That was my question that I was going to ask you. What would you do if this is an incidental finding? Incidental, leave it alone. Always. Yeah. Here's, I think, a question that's important for us to discuss. Let's suppose it's not incidental. Let's suppose this patient's got iron deficiency, anemia, or a history of rectal bleeding, and we think that this is contributing. How would you approach treating this thing and getting rid of it? Yeah, so it's changed over the years. Especially in the right colon, I've started injecting, creating a cushion, and then ablating it. I still use APC, but I guess you could use bipolar also. And I go for the central portion. If I can see the feeder in the center where it's starting to arborize, that's what I do. So I think that that's, going back to the issue of malpractice, I've seen a number of malpractice suits associated with perforation of angio-dysplasia from electrocautery. I don't know how often that occurs or what percentage of times it occurs, but I treat them with respect because the cecum is very thin. And so I do the same thing. I inject them. And then I sometimes, after I've cauterized them, I actually put two or three clips over them also. All of that, I think, is just basically what makes us comfortable. We don't have good data about it. But I would be careful about, you know, when you use argon in the right colon, one thing that happens is that the colon distends very quickly. And I think when the colon gets really distended, you know, the cecum is very thin. And everything can just look perfect to you when you're done. And then these patients have a deep enough injury to the muscular is propria that later it caves in and they have a delayed perforation. And so, you know, good rules here. Leave it alone if it's asymptomatic. And then when you treat it, get some protection from delayed. And avoid touching. I mean, it's no contact, right? When you're doing argon, the worst thing that happens. And that's the difficult part here. Colon is moving. Patient is breathing. You have to keep the tip of the probe in good distance, a little bit away from the mucosa. And if it touches the mucosa and you're pressing the pedal, then that argon goes into the wall. I think that is another thing that we have to be very, very careful about in the cecum in the right colon. Yeah, perfect. So this is an averted diverticulum. And I think everybody will probably recognize it as such. A couple of the keys to it are the slit in the middle and then the way the grooves, the anominate grooves are circling this. I think one of the things that's interesting about it is this bumpy appearance to the middle, which is very similar to the cloud-like appearance of an SSL. I actually did a study once that we published in GI Endoscopy and removed a bunch of these that had the cloud-like appearance. And none of them came back as SSL. So when you see this appearance and you're sort of confident that it's an averted tick, even if it has some features that look kind of like an SSL, you can leave it alone. This is an ulcer in the very distal rectum. And it's just a reminder that we always want to be on the lookout for squamous cell cancers. Squamous cell cancers in the anus, they can present in the distal rectum. They can present in the anal canal. You can pick them up by inspection of the perianal area. You can pick them up by your digital examination, feeling that there's something wrong. But this was an early squamous cell cancer. These are very treatable. And so you want to try very hard to pick them up. I have seen malpractice cases about this, and I've seen malpractice cases where the photograph clearly shows an abnormality. And the doctor sort of felt, you know, well, there's some kind of a benign thing. But when you see things that you can't explain, there isn't really a hemorrhoid here to suggest that that ulcer is on a prolapse, then take a biopsy or get the patient referred to a colorectal surgeon. Doug, can you hear me? This is Tanya. Yeah. Hi, Tanya. Oh, great. Hi, sorry. I have one question about the serrated lesion with the dysplasia. It's more like a practice of you and Amit. Do you, in cases like that, then you make sure you put it in its own jar? So that meaning, like, if you have, you're taking out many times in the right colon, you'll have adenomas and serrated lesions, right? And so how do you handle that so there's not this, like, mix somehow? I just think it's a practical question, perhaps. Yeah. No, I agree. So what can happen is that, you know, the portion of the SSL that is dysplastic is, it looks kind of like, under the microscope, like an adenoma. And then the other part of it looks like a regular SSL with no dysplasia. So I think it's a good idea. I think anytime we have advanced lesions, it's a good idea to consider putting them in their own bottle. When you get a whole mix of stuff, and small SSLs, small TAs, I don't have a problem putting them in the same bottle because I kind of know there was no dysplasia. Now I will say that sometimes you will, you'll send in a small SSL that you didn't, maybe didn't recognize dysplasia, and it comes back as an SSL with dysplasia and then presumably it, you know, the pathologist saw the SSL and the dysplastic portion in the same piece of tissue. So that happens. And that's, that's legit also but I, if you, if you're suggesting that you know put that in a, in its own bottle. Yes, put anything that you think is more, more advanced or has a chance of cancer. I will sometimes mix SSLs that are coming from the same section and SPS patients. You know, I mix them together, but I think that's enough of an advanced lesion to have it in its own bottle so you know where it came from. Does that- Thank you. Yeah, yeah, no, I just wanted to clarify that because I think it comes up often of what to do. So here's radiation proctopathy. And since you're both on the phone right now, I'm treating this with APC. So we talked earlier about, you know, asymptomatic angio dysplasia, don't treat them. I think the same rule applies to radiation proctopathy. If it ain't broke, don't try and fix it because when you do apply these treatments, the patient often will have an ulcer that can take two or three months to heal. Many of them will have a sense of pelvic discomfort that goes on for a while. And if they happen to be anticoagulated, they will bleed from the ulceration. I have not seen that happen really in patients who were not anticoagulated, but there's a variety of ways to treat this. This was a patient, I think if they're either anemic or they've got, you know, a lot of rectal bleeding that they're finding very distressing, then I think it's fair to treat it. And it's, you know, it's overall, these treatments are very safe. I usually don't, sometimes there'll be lesions that are in the anal canal. I typically leave those alone. I don't like to paint. So I typically will really focus my APC therapy. And, you know, here's a patient that's got a small, when you go into retroflexion, you'll often see some more. So- And you're just using forced coag here, right? I mean, you're just basically tapping the pedal as you find the space, right? I'm actually trying to hit the vessels. I see people get crazy with the painting. And if you look, I don't know if you can see the picture right now, Tanya, but we've got very individualized- Yeah, it looks beautiful. And I like that. If you paint, I think you make the ulceration worse. It takes longer for it to heal. And again, if it's not bleeding, no matter how it looks, you know, there's no mandate to treat it. So if I see it and I, you know, I see it in a patient who had prostate cancer, radiation therapy, I always would have a detailed discussion before embarking on the treatment. It's not that something awful is going to happen, but people can be sometimes uncomfortable for a couple of months after the treatment if you burn a lot of area. Okay, so we will, let's keep going here. That's more radiation proctopathy. This, of course, is a submucosal cord to recognize. This is the cecum, and this is an SSL that is surrounding the appendiceal orifice. You can see it here. So we, in our experience, we get a disproportionate number of referrals for large polyps in particular locations. And the two that are, you know, disproportion to how often they occur are the appendiceal orifice and the ileocecal valve. So I personally think you can't get this out really by standard polypectomy methods. People have described doing ESD down into the appendix. And there's a couple of approaches. One is to use the full-thickness resection device. The full-thickness resection device, if the appendix is gone, is like a no-brainer. It's the procedure of choice. If the appendix is still there, I think you have a lot of enthusiasm about the full-thickness resection device. There's about a 15% risk of appendicitis. I have a little bit of concern that there's more SSL down there. With the full-thickness resection device, you get about a half or two-thirds of the appendix out. And you can check the margin of the resection. But I will tell you that if the appendix is there, I oftentimes, well, our surgeons do this operation that we call a distal cichectomy. And it's basically the same as an appendectomy. It's just they use the stapler and they clip right across the base of the cecum. And the patient will go home the same day or the next day, and the whole thing is out of there. You don't have to worry about the appendicitis business that you do when you use the full-thickness resection device. So I will use the FTRD when the appendix is gone. And now, one thing you don't wanna have happen is send this patient to a surgeon and have them do a right hemicolectomy, because that's too much surgery for this lesion. And anyway, but what are your guys' thoughts about this? How do you like to handle this appendiceal? 100% what you're saying. So, I mean, my concern in these is first, so I get these reference too, but a lot of times, to be honest, they say it's involving the appendix, but it's not. So the first thing is to clearly inspect and see, is there any separation between the polyp and the appendix? So if there's any separation, we'll be able to remove it, no problem. The only time I have difficulties, obviously, if it's going into the appendix and you can't see the proximal extent or the intra-appendicial extent of it. And my thing is, as you said, I call the surgeon, make sure that they understand this is why I'm sending them. They don't have to do a right hemi. They just have to remove the appendix with a little bit of cuff of the cecum around the appendix. It's a quick procedure. Even with the FTRD, if they've not had an appendectomy, I'm just concerned whether, because I don't know how deep into the appendix it's going and how much of the appendix I'll be able to get in because with the FTRD, it's what you get is what you get. I mean, there's not much maneuverability after a certain point. And I don't want to be unsure that I haven't got the entire thing out, especially in young patients. So that is my thing. But obviously, if they've had an appendectomy, then it's much easier. Yeah, I agree with that. And I think the point you made, Amit, is really good that the key to whether or not you can resect it endoscopically, for most of us who are just humans with regard to resection, is can you identify the entire margin of the lesion, even if it goes down into the appendix a little bit? And when you do inject it, the rule that I follow is just like I would with the ileocecal valve when it's going into the ileum, I usually inject into the orifice first. And you want to be very slow with your injection because the appendiceal orifice does not lift. It just stays put. So if you inject a lot, all of a sudden you're working down in a funnel and it becomes very difficult. And so anyway, so those are some thoughts about that. So this, I hope everybody recognizes this as a cancer. And obviously this is a big ulcerated lesion. And if I asked you, did this arise in an adenoma or in a sessile serrated lesion? Your answer, of course, would be it arose in an adenoma because you can see over here on the right side of the lesion, this nice type two pattern that is still intact. And of course we don't always see this in cancers, but a lot of times we do. I think this is a relatively advanced cancer to see this. This can't be removed endoscopically, but it gives you a nice sense of the nice three pattern. If you look in here, you can see this completely disrupted vascular pattern down in the ulcer that is in this cancer. And that is that amorphous disrupted vascular pattern is up here at the top, the normal nice two pattern. But this disrupted thing tells you that there's at least deep submucosal invasion. And so I think it's kind of a nice example of seeing that. That's in lesions that have pseudodepression and a non-granular lesion with pseudodepression, we inspect that vascular pattern very carefully and look for areas of disruption. When there is an area of disruption, it's usually associated with some change in the morphology, you know, sort of a dip or a depression or something. But anyway, that is nice three, if ever it existed and, you know, very disrupted vascular changes. Okay, this is, when you see this in the right colon, what are you thinking? I mean, my thought is always that- Not taking the split dose correctly. Yeah, we find about 15% of our patients, no matter what we say to them, they will not split the prep. They will end up taking the entire thing. Or taking the second dose much earlier than, because, you know, if it's an early morning colonoscopy, they have to wake up at three o'clock to take it. And they don't do that, they take it at nine or 10 and then go to sleep. Yeah, this is just an example. That's just an example of a flat adenoma. I don't know if this would be considered a 2B. I think most of the Paris 2B lesions, the truly flat lesions that I see, are serrated lesions, sessile serrated lesions. But this is an adenoma. You can recognize it because these pits are elongated and you see the blood vessels are a bit thicker around the pits. The margin of it is kind of indistinct, but that's an extremely flat adenoma. Okay, how would you characterize this lesion? What is the morphology of this lesion? And our choices, let's say first of all, granular or non-granular. And then secondly is, I would say that this is non-granular. We have a little bumpiness on the edge, but if we have this area in the middle, that's pseudodepression. So I was explaining earlier that the most worrisome morphology that we encounter really in routine polyps is the non-granular lesion with pseudodepression in it. And this is gonna, it's got at least a 50% chance of high-grade dysplasia and probably 15, 20, depending on the series, 30% chance of invasive cancer. And this is not lifting well. So that is the non-granular lesion with pseudodepression, scurious lesion that we see that doesn't have overt cancer in it. So here we see a couple of clips and we're looking down the scar toward the left. And I think the question is, it does this, we always want to inspect our EMR scars with a white light and with some kind of electronic chromoendoscopy and preferably with a magnification. So we have the near focus on now. And this is interesting because it shows the contrast where the marker is right now, that is scar tissue that is actually normal, right here, that's normal. But if you look just across that, you will see recurrence, that's recurrence right there. And it just has a nice two pattern. Obviously this was an adenoma. We would expect recurrences to have the same pattern as they have as the original polyp, but this is the border of the adenoma. And dealing with this, the main issue is that we've got scar tissue. That thing is not gonna lift if you inject it. So we typically would either snare this off or remove it by avulsion, but very important to be able to recognize recurrences and to be able to recognize the things we've been talking about, clip artifact, and just the normal scar. Depending on when you catch that normal scar, that tissue is not quite the same as the normal colonic tissue. It still may have some inflammation, still sort of in the healing phase of that. Here's another area, we see this a lot. The doctor has taken off part of a polyp, usually the distal, the rectal side of the polyp, and there's some residual tissue here. Now, if this tissue extends way out, because sometimes you'll have a two or three centimeter polyp out there with the distal edge removed, I would still lift that. But for something small like this, I typically would just snare it. And I think Amit's gonna talk in detail about different options that you have for treating recurrences. When you, okay, Amit's gonna talk about that, because after you snare it, do you burn more at a site of like recurrence or incomplete prior resection? Yeah, it's a good point. I'm sure Amit will discuss it. I will tell you, because we don't really have randomized controlled trials, as you know, Tanya. So what I typically do is I will snare it. If I can't snare it, then I evulse it. And I like to use hot evulsion, but some people use cold evulsion and then burn it up with the snare tip. That's the cast technique. I think Amit's gonna talk about that. But I will snare it hot, burn up the margin. And I used to use APC for that. And now I usually use the snare tip on soft COAG. And then I usually clip it. Amit, I know you're gonna talk about a variety of methods. Do you have a go-to? In terms of, so my approach, which we'll talk, is depending on how much their recurrence is, how big. So obviously I want to remove as much as possible with snare, either lift, snare, lift and cautery or underwater. Then I try to evulse by hot evulsion. That's my go-to rather than cold, because with cold, there's some bleeding and then it kind of, the visualization gets all murky. And then final would be just a blade with the tip of the snare. I mean, I have stopped using APC at all. I mean, extra device, more time and costlier. Very good, very good. Okay, so ripe colon. I can tell you that there's a whole bunch of these lesions. They're covered with normal mucosa. I actually usually get a referral every year or two to deal with this endoscopically. And so what I usually do is take a catheter, a needle cap. This is pneumatosis. Stoides, of course, is not too much else that will do this in terms of the number of these lesions. But I usually will take a needle, put it down the snare, push all the air out of it, stick a needle in and just suck back one or sometimes two of these. They immediately collapse and then take the catheter out, empty the contents. And usually there's nothing in there. Whereas if it's a fluid built thing, you know, you'll get fluid back. But you can make just a visual diagnosis here of pneumatosis stoides. It's a benign condition. You can also verify it by CT scan. I think I'll skip this one. Ahmed, I'll just do a few more because I think we're running out of time. This is one I think you want to be able to recognize. This is a soft lesion that it has a cushion sign kind of like a lipoma, but instead of being yellow in color, it has a kind of grayish color to it. And, you know, I probably have seen maybe 15 or 20 of these over the course of my career. Here's another one that's maybe a little more obvious. I think you can tell that the color of that is different than a lipoma. And if this was hard, you know, I suppose I would think it's a, you know, it might be a gist or maybe something extreme. You can see it's really soft. Ahmed, what are your thoughts about that? Lymph? Lymph? Lymphagia seal, sorry. Yeah, lymphagia seal. This is a lymphagia seal, or you'll see it called a lymphatic cyst. And I've only seen one patient that had more than one of them. They're usually isolated. They can be pretty much anywhere in the colon. I don't think I've seen one in the rectum. And it's just good to be able to recognize it and ignore it and just kind of move on. Let's see, I'm going to do, I think I'll do one more, this one, right? No, oh yeah, let's do this one real quick. Maybe we'll do, we'll do two more. I've got about, I've got quite a few of these, but Ahmed, what are your thoughts about this? Is this a polyposis? Lymphoid follicles, right? I mean. These are lymphoid follicles. So the key, I think, to recognizing lymphoid follicles is the clear center. And if I go back there for a second, excuse me. I'll go back. Lymphoid follicles, they always have this clear center. And so when you see that something that's elevated, I think we all have resected these at one time or another, but sometimes some people have a very exaggerated pattern of them. They're usually more often in younger people that there'll be real exaggerated. But in MBI especially, you can see that clear central pattern. And that tells you it's a lymphoid follicle and you can leave it alone. Okay, we'll do one more and then we'll start the lectures up again. So this is a lesion in the right colon. It's actually in a patient that was referred to me for resection of an SSL that I had already taken out. And then I saw this. So this is, you know, the morphology of this is cancer. And we'll see it here in MBI in a minute. And you can see that it'll have the nice three pattern in the base of this. The vascular pattern is disrupted. So the question is, is this cancer arising in an SSL or is this cancer arising in an adenoma? And I think the clue to that is right over there on the edge, this area right here, where you see the typical pattern of an SSL. There are no big white tubular pits of an adenoma. There are no blood vessels. That is the large open pits of an SSL. This is an SSL with cancer in it. And, you know, I don't have many videos of this. I don't know if you guys do. I have tons of video of polyps with adenomas. And when, you know, when we looked in our own database at the prevalence of cancer in SSLs compared to adenomas of similar size, we found that cancer in adenomas was seven times more common than cancer in SSLs of comparable size. And I think it gets at the fundamental issue of why SSLs are dangerous. Are SSLs dangerous because they are more likely to have cancer or are they dangerous because they're more likely to be missed? And- I think latter, right? It's the latter. It's the latter. I think it's- Because the average age of SSL with cancer is higher than adenoma with cancer. That's one thing that's been shown. So they're slow growing, but when you miss it, they will ultimately grow to become cancer, I guess. I don't know. Yeah. I think that's absolutely right, Amit. And I think that, you know, we shouldn't be too worried about individual SSLs. When you see an SSL, yes, get it out, get it out effectively, but immediately start thinking about what else is in the vicinity, because it's not the SSL, you know, that you see and that you got out that's going to cause the cancer or the interval cancer. It's the one two folds behind you that has splasia in it, that you haven't seen yet. So when you see big SSLs, be thinking about whether or not there are more SSLs. My fellows, we've shown this. We play a game in our endoscopy unit just about every- I have the fellows with me half the time. So when the fellows are with me, we play this game where I will let them examine the entire colon and then they go back to the cecum and then I come in and examine them. And I will say that their miss rate for SSLs is scary. And even for large SSLs, they miss a significant number of them. I think they've gotten better with time. We've tried very hard to get them tuned into it, but I do think it takes longer to learn the patterns that Tanya was going over for us this morning. Those very subtle changes in the texture of the lesion compared to the normal mucosa, the color differences are not as obvious. So you have to use a different set of clues and be thinking about, with regard to SSLs, be always thinking about what you've missed.

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