So, we'll open it up to Q&A now, and I'll start us off. You know, endoscopy units vary in size, right, and the number of procedures they do. But most ASCs and centers do screening for endoscopy off in direct book. And so, how do you advise Shivangi units that maybe are smaller, should they all be keeping over-the-scope clips in their unit, and how do you weigh that in terms of expertise available when most of us are taking out large polyps? Right. So, I think even with the screening colonoscopies, we all know, you know, there are risks. And if it is a small perforation, I think endo units now with the armamentarium we have should definitely have endoclips and over-the-scope clips to be able to close small to medium-sized perforations. And as I said, you know, it's okay to bring in a colleague. And if you don't feel comfortable using a certain device, seek for help. And I definitely feel we should have an expanded toolbox, even if we are scoping in the ASC settings. Wonderful. Thank you. This is primarily for Dr. Woods, but also for the whole panel. Could you discuss use of cold snare for EMR in polyps, let's say approaching 20 millimeters or 2 centimeters? You know, what's the data in terms of recurrence rate, risks, any other things that you want to talk about? Sure. In such a short talk, we couldn't talk about other techniques, but underwater mucosectomy with a snare is obviously an emerging technique that can allow you to take up to a 20-millimeter snare. I think even though in these talks, the guidelines and literature is great, but we also need to be thinking about the specific issues surrounding that patient and the location where you're doing a resection. I'll just throw out a couple ideas that can really change the way that you approach that. If you're in ASC and you don't have all the technologies with you, you may decide that you want to go ahead and just close it. If you're in a hospital setting and you have the ability to watch a patient overnight, you may be a little bit more or less conservative and just see how that patient does. But from a perspective of getting recurrence, that really comes down to your technique. You want to make sure, as we saw Dr. Berzin's talk, you want to make sure you get that Saturn sign. You want to make sure you get enough normal tissue around the target lesion to make sure that when you actually grasp that you actually remove that lesion. Incomplete resection is an incomplete resection, no matter if you use cold or hot. But of course, whenever you use electrocautery, in my opinion, I like to lift to decrease those risks for bleeding and also perforation. That cushion of fluid and whatever, if it's gel, if it's going to be for me, I like 5% saline, I'm sorry, 3% saline with three mLs of methylene blue to give just a little bit of color. To me, if you can get it in your pharmacy, allow you to have it on your unit, you can use it in much volume, much more volume than some of the other commercially available vials. But when it comes down to just the safety, it really comes down to your experience, where you are. And then lastly, something that now in my career I'm having to deal with is patients that don't live locally that are coming in. And how do you handle those patients? So again, it's not just purely about the removal or the technique, it is thinking about if that patient needs to go back on anti-coagulant or back on anti-platelet therapy. In those cases, I'm really conservative and I close all of them. And as we think about it, there's not really necessarily a size limit for using a cold snare. You can use a cold snare on a gigantic cecal polyp if you want, it is a little bit less efficient. We're at a really interesting moment in the field right now, because you'll have one room at DDW where everybody's talking about cold snare is the future. It's piecemeal, it's safer, a little bit of recurrence is okay. And then the next room, ESD is the future, it's on block, it's a little higher risk, but it's worth it because we can get very, very low likelihood of residual. My belief is that in general, outside of early cancers, piecemeal is completely fine. And so safety-wise, it's very clear that for large polyps, piecemeal, a cold snare is probably the safest way to go. So to your point, Kevin, if I have somebody who's traveling for two hours away and I'm worried they'll get a post-polypectomy bleed tomorrow, post-polypectomy bleeds almost do not occur using a cold snare, and you can remove quite large polyps with a cold snare. Great. And then question for you, Tyler. If you have a patient with a FAIR prep, how do you manage that? Do you clean and struggle through it? Do you have them come back? When do you make that decision and what do you recommend? Well, I'll tell you first what I'm tempted to do and what I try not to do. What I'm tempted to do is do a pretty good job and say, well, you should probably come back in like, I don't know, two or three years or maybe five, but probably not 10 because it was FAIR. That's a very messy world to play with. I think ultimately, despite the fact that there are many, many bowel prep scores, I think it is either adequate or not adequate. If it was adequate, you go with your formal surveillance intervals, five, 10 years, whatever. And if it was inadequate, that colonoscopy didn't count. My suggestion is not to get into a scary middle ground of a couple of years it was FAIR. So my goal basically is if it starts off as what I would consider FAIR, I work really hard to make sure that I can get it clear enough to see anything within just a few millimeters in size. And if I cannot do that, then I will call that an inadequate bowel prep and have the patient come back. Actually, I tell my fellows, at that point, you're doing the patient a disservice if you are trying to over-credit them for the prep because you could have misleasions. You're better off bringing the patient back with a better prep because that's going to be a better service to the patient. Great. Good discussion. This question here for the group, there are several cases when you have difficulty transversing the sigmoid and then suddenly you can't advance or withdraw the scope and it ends up being in a hernia. What do you do to manage that when ahead of time you didn't notice a hernia? Are there any specific tips? Go ahead, Shivangi. So the colon is in a hernia? The scope is in a hernia and stuck. Yeah, I would pull out at that point because you do not want to push through the hernia because the colon is going into the hernia and there is an exit point and that loop itself can cause a perforation. So actually, that's a great question. You always want to make sure if you're not able to push the scope and feel like it's not advancing, lift the gown and look at the abdomen. I've seen colons herniate into the scrotum and the light is shining in the scrotum. So you have to be very mindful where the scope is going, you'd be surprised. The second half of the question I think gave me palpitations because I've had this happen. I think the person was also asking if the scope is stuck in a hernia and I've had that happen before. And it is a very dark moment in the midst of your busy colonoscopy day. In virtually, I think one of the things to remember is that particular moment is not yet an emergency. And so you have five minutes, 10 minutes, 20 minutes, all the time in the world to reposition, to gently move things around, to try water, to just do lots and lots of things. So I've had it happen twice. And both times when I pulled, it felt like there was no way on the planet the scope would ever come out. And eventually, we were able to get it out safely just by not rushing and taking our time. But it is a dark moment in your endoscopy day. Maybe we'll start with you, Tyler. What is the role of cold forceps in polypectomy? So it's diminishing dramatically. It doesn't mean you can't ever use them. For very small polyps, zero to three millimeters in size, I think it's fine to use cold forceps if you like. In particular, if a polyp is in a particularly difficult position in some quadrant on the upper edge that you just can't get a cold snare around, I think it's fine. You should really be avoiding any piecemeal forceps polypectomy. So if the entire polyp does not fit comfortably into the cup of the forceps, that's generally not the polypectomy you should be doing. I'll also make the point that some people use forceps because they're scared to lose the specimen. And that is a frustration with a cold snare. Sometimes the specimen drifts away. And that is fine. It is better to get a whole polyp off successfully and not necessarily have the specimen than to get 80% of it in the forceps and send it to pathology. So I do not lose sleep over losing a couple of cold polyp snare specimens floating around in the fluid. I don't spend too much time actually even looking for them. Let me add to that too. When you find yourself in that position where you're using a small biopsy forcep, don't forget about the power of APC. So if there's areas that you just are not cleaning up, especially in a large polypectomy, APC, the edge, also that's been sustained. Of course, if it's just a benign lesion, if you believe you're working with potentially malignant lesion, of course, that may not be the right move, but think about APC as well. All right. I think we have time to squeeze in maybe two more questions. So second to last one, Sarvangi, if a patient comes in, has their colonoscopy, you don't suspect anything, but now they have abdominal pain, distension, tenderness, what's the first test you order? And how do you manage it? How do you decide whether to admit them or not? Yeah. So I have a very low threshold to get an x-ray. Again, you don't want to get a supine x-ray and wait for the patient to wake up. You get a good quality free air series and depends on what the intervention was done. If you took out a large polyp, you could be worried about a post-polypectomy syndrome and may not see true free air versus if it was like the difficult colon and there was a lot of pushing, shoving, and you do anticipate a perf. As I said, I have a low threshold to get a CAT scan. The first thing I personally get is a free air series and see where we stand. But if the patient is definitely was fine before and now complaining of a lot of pain and tenderness, I have a very low threshold to admit them, watch them, and maybe if the symptoms continue, get a CAT scan. And again, as I said, if you're suspecting a dirty perf, you're going to start antibiotics, but you're watching them closely in the hospital setting. You're definitely not sending them home without either the symptoms getting better and suddenly they've passed a lot of air, they feel better, and the abdomen is completely benign and patient is reliable. They live close by. You also, unfortunately, have patients coming from two, three, four hours away. So at that point, you are weighing if the patient can stay in town or you're admitting them and balancing all of those things. Thank you. And we'll squeeze in one last one, but we'll make it quick. In regard to duodenal polyps, and you can start this one, Dr. Wood, can you use a cold snare? And the question is saying, given the risk of post-polypectomy bleeding. Yeah, I think the duodenum is a very, very humbling place to work, especially even with the best of hands and even with lifts I've perforated. I think that's when you have to really think about, are you ready to close? I will say not a cowboy at all, but definitely I'm always thinking about what if I perforate and do I have everything in place in my unstable position? I'm always using CO2 as we talked about, but I think you have to be really, really, really conservative when you're thinking about taking a polyp. You don't want to do that in the middle of a, if you find it incidentally, bring the patient back, give yourself an hour, don't take that lightly. So I think it's safe, but you also need to be always prepared to close. Thank you to our wonderful speakers and for the audience being so engaged. We will take an eight minute break and come back here at 1150 for our next session. Thank you, everyone. Thank you.

endoscopy procedures

over-the-scope clips

polypectomy techniques

inadequate bowel preps

colonoscopy complications