All right, if everyone can get back to their seats, we can start on time so we can continue the debate and the learning process. This is something which is very close to what we, most of us, do every day, so we're going to talk about colon cancer and polypectomies. The first speaker today is Dr. Charles Kahi from Indiana University in the VA Hospital there. Bring your poll up recognizing the margins and selecting the right approach for a section. Thank you very much to the course organizers for the kind invitation, and thank you for the audience for soldiering through a long day. This topic is really germane to general GI, and my goal in the next 20 minutes is really to provide you with a framework on how to approach polypectomy and selecting the right approach with the understanding that there's a lot of nuance and details that we can't possibly cover in the next 20 minutes, but I'd be happy to address, hopefully, in a productive discussion session at the end. No disclosures of any kind. I always like to start the talk with the high-altitude perspective, and really high-quality polypectomy is indissociable from high-quality colonoscopy, really. In the past, we used to be focused on detection, detection, detection, which is, of course, extremely important, but detection only goes so far if we don't really have effective ways of eradicating the polyps that we are finding. We've known for some time that polypectomy quality is variable and operator-dependent. The CARE study, which is a landmark study in our field, of course, by Heiko Pohl and his associates, quoted an incomplete resection rate of about 10 percent, but this varied tremendously between endoscopists and was up to 23 percent in some instances. And that's not just an observational issue. This incomplete polypectomy, when they followed this cohort over a long period of time, they found that patients who had had an incomplete polypectomy were three times more likely to present at surveillance with something bad, an advanced lesion, in the same segment where they had a polyp before. And if you look at this from the even higher-altitude colonoscopy quality perspective, this is a significant contributor to the burden of post-colonoscopy colorectal cancers, so cancers that appear after a colonoscopy in which no cancer was found. And depending on the case series you look at, studies that did root cause analyses of PCCRCs, up to 15 percent of these cancers are attributable to incomplete resection, so very important to get this right. Now we have to start this talk by really nailing down the macroscopic features of polyps, not just to really go into this somewhat detailed description for the sake of it, but this description is really germane to the discussion about which polypectomy technique is best for an individual polyp, but also to identify polyps that are not appropriate for polypectomy, standard polypectomy in the first place. Now we're all familiar with the Paris endoscopic classification, which has polypoid lesions, the ones we are mostly familiar with, pedunculated 1P, sessile 1S, non-polypoid lesions, type 2A, which is minimally elevated, 2B, which is truly flat, 2C, which is minimally depressed, and type 3, which are excavated or ulcerated lesions, and the important ones not to miss here are type 2C and 3, because they can harbor advanced neoplasia even at small sizes. We also utilize the NICE classification, which is based on narrow band imaging, that allows us to really predict the histology of an individual polyp. Again, I'll circle back to that point repeatedly during the talk. That influences directly the polypectomy approach. Type 1 polyps are lighter than the background mucosa. They have no or isolated lacy vessels on the surface, and on the surface they have dark or white spots of uniform size, whereas type 2 polyps are darker, browner compared to the background. They have brown vessels that surround white structures, and they have oval, tubular, or gyrating structures, which are surrounded by brown vessels. Type 1 lesions are hyperplastic and sessile serrated lesions, or serrated lesions overall. We can differentiate these two type of lesions. I'll come back to that in a minute. Type 2 lesions are adenomas. Type 3 lesions are the important ones to really be wary of. These lesions have areas of disrupted or missing vessels, and really an amorphous, absent surface pattern, and they are associated with deep submucosal invasive cancer. We also utilize the KUDO PIT pattern classification, and briefly also allows you to differentiate between normal mucosal hyperplastic polyps and adenomas, but the ones to be really careful with are those that have irregular arrangements of PITs, or loss of PITs, or a disorganized arrangement, 5i and 5n, and those are, again, associated with advanced histology. We'll push this one step further. Don't be taken aback by the plethora of images here, because this really, the WASP classification just builds on the NICE classification I presented two slides ago. The idea here is to be able to differentiate hyperplastic from sessile serrated lesions with high accuracy, because, again, that influences the resection technique. And if you have either type 1 or type 2, and at least one of the two following features, clouded surface, indistinctive border, irregular shape, or dark spots within the crypts, you can tell that this is really a sessile serrated lesion with high accuracy. If you have a type 1 without any of these two features, it's a non-neoplastic or hyperplastic polyp. If you have a type 2 without any of these SSL features, one of, two of these four, then it's an adenoma. All right. As I said, the first step really is to recognize the polyps that really are a no-go with regards to polypectomy. I think everybody remembers this, you know, from histology course during medical school. By definition, invasive colorectal cancer is basically invades the submucosa, breaches the muscularis mucosa. Now, TIS lesions in the TNM classification, the cancer gets into the muscularis mucosa but not quite through it. The more relevant lesions to our discussion today are T1 lesions, which go beyond into the submucosa. So here you can divide those into those who have superficial submucosal invasion, so it's less than 1 millimeter or 1,000 micrometers, and those that have deep submucosal invasion, which is greater than that 1 millimeter mark. And good news here is that we actually have good ways of identifying deep submucosal invasion, more than 1 millimeter, using surface features. And that goes back to the morphological characteristics I described earlier. Paris classification type 3 or Kudo classification type 5 polyps are highly associated with deep submucosal invasion. You have other features, non-lifting sign, which you can also see in benign causes such as submucosal fibrosis, chicken skin appearance, expansion, firmness, fold conversions, and so on, are also associated with deep submucosal invasion. Now, how do we approach these lesions? Well, it depends on their overall morphology according to the Paris classification. Sessile or flat lesions, so 1S or 2A and 2B, those patients are better served by surgery. Biopsy, tattoo if not in the cecum, and then refer accordingly. Pedunculated lesions are actually a little bit different, and hopefully we'll have some time to cover that towards the end. But by convention, all pedunculated lesions, even if they have features of submucosal invasion, are candidates for endoscopic resection because they can have histologic features that are actually favorable, and you could accomplish cure with just endoscopic resection. Just images of these are some of the features I described before, fullness, firmness, ulceration, chicken skin appearance, fold convergence, again, these are cancers and are not candidates for resection. We don't do very well with superficial submucosal invasion in terms of being able to predict it using morphological features. I won't cover this in great detail in the interest of time, but, you know, this discussion is mostly pertinent to laterally spreading tumors or laterally spreading lesions, which are polyps that really grow horizontally or sideways and are larger than 10 millimeters. And you can classify those into different types, granular and non-granular, and then within subtypes, within those two broad categories. And there's a gradient of risk here between homogeneous granular LSTs all the way to pseudodepressed non-granular LSTs with pseudodepression, going from about a 1, less than 5 percent risk of submucosal invasion all the way to 30 to 40 percent in this situation. And because of this increased risk of submucosal invasion, these lesions really require on-block resection, whatever that is method is required to accomplish that, because you need that to estimate the depth of the lesion and whether the resection was adequate. And in that situation, you really ought to refer these patients to a specialized endoscopist for attempted on-block AMR or endoscopic submucosal dissection. All right. So we move on to the actual polypectomy part of this talk, where everything I'm going to say from this point on assumes there is no submucosal invasion, and we've done due diligence in diagnosing the polyp, and there's no concern about any invasive cancer underneath. In non-pedunculated polyps, the first decision node really is to decide if this is a serrated lesion. And that's where we recommend going with cold-snare polypectomy or a cold EMR. Is cold EMR really reserved for lesions that are 10 millimeters or larger? And that's really my practice is to do EMR with submucosal injection, of course, for these lesions. Cold EMR for serrated polyps that are 10 millimeters or larger is associated with very low recurrence rates. It has very low immediate and delayed bleeding rates, both less than 1 percent, almost zero rates of perforation. And I'll add that virtually no upper size limit to the serrated polyp that you can tackle with EMR. And you also don't really need to do anything beyond the actual resection. You don't need to ablate the margin. You don't need to apply a clip in the great majority of cases. Serrated polyps can be tricky, though, because they're hard to see and detect sometimes. And because of that, they can also be hard to resect. You can't see it. You can't really know if you did an effective resection. Things that to look for, those are some of the telltale signs of a serrated polyp. The classic mucus cap, of course, that's the most common alert signal that you have a large serrated polyp hiding underneath. These lesions have a lot of goblet cells. That's why they secrete a lot of mucus. But it can be very subtle, a rim of debris or bubbles, alteration of the contour of a fold or interruption of an underlying mucosal vascular pattern. This is a patient I scoped earlier this month. I really have to have this visual memory in looking at changes in pattern as you're withdrawing your scope and looking around. Here you can see those blood vessels look fine and sharp and crisp here, but they become vague, almost dissipate in this area. And you can see almost like a geographic outline on this side. So is there a lesion there? Sure enough, in MBI it becomes a little bit more obvious. This is an SSL. It has an irregular shape and borders that really fade into the surrounding mucosa. And the best approach for this type of lesion is an EMR, not because you just really want to inject the underlying submucosa to protect it, but because when you do that and use a dye, you're actually able to delineate the borders of the lesion very effectively. And a cold resection can ensue after that without any difficulties. This is not the same polyp, but it's essentially the same principle to how we approach these. Injection with submucosal fluid with a dye will allow you to lift the polyp and identify the margins with clarity. And then you just go around the polyp like any normal cold polypectomy, resecting this with ensuring that you're taking a nice margin of normal tissue, two to three millimeters, as you work your way around the lesion. And water jet really helps you tampon out these small bleeding vessels that you often see in this situation. Okay, so we move on from this first decision node. The next one is really to look at the size of the polyp. For polyps that are less than 10 millimeters, so diminutive, five millimeters or less, or small, six to nine millimeters, cold-snare polypectomy rules and is really the standard of care for this size range. We used to call this issue, the movement, the cold revolution, but, you know, in the case of small polyps, it's really the cold standard now. It's the revolution is done. This is really what needs to, the best technique for polyps in this size range. Very important to master. More than 80 percent of the polyps we encounter in practice are in that size range. And the risk of submucosal invasion is extremely low. So you're not really risking leaving something bad behind by using cold-snare polypectomy. And the ASGE ACG task force, now actually in the very newly issued guidelines, includes this as a quality metric. The percentage of small polyps, four to nine millimeters, that are resected using a cold-snare should be 90 percent or higher. And that's a 1A grade recommendation. I won't elaborate much more on cold-snare polypectomy for small polyps. I know Dr. Shami will cover this in the next talk, but I'll just leave you with this randomized control trial published in the Annals of Internal Medicine. Four thousand polyps in four to ten millimeter range, comparing cold-snare polypectomy to hot-snare polypectomy. And the study's primary outcome was adverse events. And look at those rates. Eight percent post-polypectomy bleeding compared to 30 percent for hot-snare polypectomy. Severe bleeding, the patient needed to be hospitalized, have another colonoscopy, one percent to eight percent. And cold-snare polypectomy was more efficient. You needed less time to do it. All this combined with really very similar efficacy numbers on block resection and complete histologic resection. So it's safer and works as well and is more efficient. We move on to intermediate-sized polyps, the next decision node here. And you'll see in this box pretty much everything is mentioned, cold or hot-snare polypectomy, cold or hot EMR. And this isn't a situation of, you know, any of these would work. The intermediate-sized category is a little bit tricky because there's a lot of nuance in which technique is actually best for a given polyp. And we are in a paradoxical situation, actually, where we have really good data for what to do in polyps that are less than 10 millimeters and polyps that are 20 millimeters or larger. But that gray zone in between, the 10 to 19, is still an evolving field. Now, this is a non-inferiority randomized trial that attempted to look at this issue more closely, spearheaded by my colleague and friend, Dr. Rex. This included 286 polyps, 6 to 15 millimeters, so up to 15 millimeters within that intermediate-sized range. Forty-five percent of those were in the 10 to 15 millimeter range. And seven polyps overall were incompletely resected. Now, interestingly, all seven of these polyps were in that 10 to 15 millimeter range. Six of the seven were resected using hot techniques, either snare polypectomy or EMR. One cold EMR, none in the cold snare polypectomy. And there were only two serious adverse events, delayed bleeding, which were in the hot arms as well. None occurred in the cold snare polypectomy or cold EMR groups. Now, that doesn't mean that we can do cold snare polypectomy or cold EMR for anything in the intermediate-sized range. You can consider cold techniques first, and you should use cold techniques for serrated polyps. But there are polyps that really are less likely to be effectively removed with cold resection in that size range. And those are that essentially are difficult to just transect with a cold snare. So larger size, so on the upper end of the 10 to 19 millimeter range, remember that RCT I showed went up to 15. What to do in the next category, 16 to 19 and 20, becomes a little bit murkier. Or polyps that have really a lot of bulk are difficult to go through. Adenomatous histology is associated with lower complete resection rates than SSL. And difficult location and indistinct borders are, of course, a factor. Again, another polyp I worked with earlier this month, you can barely see it in forward view. It was one of those difficult colonoscopies, tortuous colon, looping, redundancy, just very difficult to get a good view on the polyp despite using a cap. Even though the polyp, I probably could, if it were located in any other area in the colon and I was able to expose it and keep a stable scope position, I probably would have tackled it with a cold resection. But in this situation, I had to retroflex on the right side and do essentially a hot EMR in order to accomplish complete resection en bloc. And that was my goal in this situation, really the effective resection. I knew I had a very narrow window of opportunity before I lost control of the polypectomy area. So really this just underscores the importance of going through that toolbox of polypectomy techniques when you approach these lesions and pivoting from one technique to the other depending on patient characteristics. We'll move on to the next category, large polyps, 20 millimeters or larger. And these, we recommend doing EMR for those, cold EMR or hot EMR. Now, interestingly now, we have high quality RCTs that tell us, that give us a clearer picture of what works best in this situation. The German chronicle RCT came out in gastro very recently. The primary outcome was major adverse events. And you can see here, cold EMR was much better than hot EMR. The rate of adverse events was 1% compared to about 8%. The tables are turned when you look at efficacy. The residual or recurrent polyp rate was much higher for cold EMR compared to hot EMR. There's another recently published RCT as well from Australia, from Mike Bourke's group, which was published in Gut. Now the interesting thing about this trial is that they completely excluded serrated lesions because the investigators deemed that these are, there's not much debate there. These are better tackled with cold resection techniques. So they wanted to look only at the purely adenomatous pathology. And almost all of the lesions were Paris IIa, flat, slightly elevated lesions. Again, similar story overall though. They looked at recurrence rates at six months after the first colonoscopy. For cold EMR, look at this recurrence rate, 22% compared to only 1.6%. However, when you look at adverse events, again, it's the mirror image of that. The hot EMR was significantly worse than cold EMR. There were practically no adverse events in the cold EMR, 0% for deep neural injury, perforation, per procedure of bleeding, compared to 26%, 11%, and so on. One final RCT to show you here. This is still in review, but will be published soon. The North American experience comparing cold EMR to hot EMR, again, a similar story. There was higher rates of complication in the hot EMR group. But this was counterbalanced by lower efficacy in the cold EMR group. The devil is in the details, as always. They really looked at features that predicted failure of cold EMR for these large polyps. Within that subgroup, a size of 30 millimeters or more advanced adenoma testology or adenoma with high-grade dysplasia were associated with failure of cold EMR resection. That is, these patients had higher rates of recurrence at six months. Conversely, a smaller size within that large size category, so 20 to 29, or cess-acerated lesion testology where there was no significant difference between cold EMR and hot EMR. So how do we synthesize these trials? Overall, cold resection is associated with lower complication rates, but higher recurrence rates. SSLs should be resected with cold EMR. When it comes to adenomas, though, it's really a tradeoff between safety and resection completeness, and you really have to individualize that decision based on specifics. Overall health, frailty, anticoagulation status, are they likely to come back for follow-up? All of these factors have to be taken into account. So hot EMR is the way to go if the priority is to mitigate recurrence risk, and to be honest with you, that's probably my go-to approach unless it's a serrated polyp. But if the overriding goal is to mitigate complication risk, then cold EMR is an acceptable alternative. Five seconds on pedunculated polyps. All pedunculated polyps, I said this at the beginning, even with features of deep submucosal invasion, are candidates for endoscopic resection because histological features may still be favorable, but there's an art to it. These polyps should be resected and retrieved on block to allow the pathologist to give you useful information, and you should really aim for an R0 resection where you're going really far down on the stalk, close to the colonic wall, mid to low stalk, to be able to increase the chance of doing that. Hot snare polypectomy is recommended if the polyp is larger than 10 millimeters, and we all have stories of epic stalk bleeds when we try to remove them with cold resection techniques. And the multi-society task force for colorectal cancer recommends prophylactic mechanical ligation of the stalk with either detachable loops or clips if the head is large for really large polyps, a large head or a thick stalk. So take-home points. The art of polypectomy is really becoming a science. Gone are the days of heuristics and, you know, doing things because that's how I was taught. We have now high-quality RCTs that inform these decisions, but really the best approaches have to take into account polyp and, very importantly, patient specifics. Step one, especially for larger polyps, is always, always this OCD assessment for features of submucosally invasive cancer. Pay special attention to serrated lesions and keep your radar out for these subtle features. The margins may be tricky and need special attention, but if you see them well and you inject them and highlight the margins, cold resection works very well and is quite safe. And individualize your decision for larger polyps. Thank you very much. Thank you, Dr. Kaye. That was a great way to explain how to deal with a polyp, but it looks like you've already set up the stage for Dr. Vanessa Shami from the University of Virginia. And she's going to tell you what to do and what not to do when you do cold polyp resections, cold snare resections. Well, I wanted to thank the course moderators, and really it's a pleasure to be here. And a little bit's going to be a duplication. I do want to acknowledge my colleague, Andy Copeland, who also gave me some of the material. So these are my disclosures and in no way will influence my talk. So this whole concept of the cold revolution, you know, we think of it as being heat versus cold and it's really not, right? It is, but it's not. It's just you've got to pick the right polyp and the right technique. And as time goes on, we're going to define better, as Dr. Kaye just showed us, about which polyp to use, which technique. So I'm going to talk about why cold snare is preferable, which polyps should be considered for cold resection, how we accomplish cold snare EMR or cold snare polypectomy, what the data on adverse events are, and what the data is on recurrence. So why should we do cold snare? Why is it preferable? Reason one, less equipment, right? You don't need an electrosurgical generator. You don't need a closure device, imagine that. Smaller pieces don't need a large Roth net, so you don't have to go in and out in large serrated polyps. And there's a cost savings, right? I mean, each time we place a clip, it's expensive. So these are potential pluses. The other reason is there's less risk, as was mentioned prior, bleeding, perforation, and obviously, if you're not using heat, you're not going to have any electrocautery syndrome. So why would it not be preferable? Well, what if I compromise my pathology? This is a piecemeal technique, and am I really getting all of the polyp? And what about the rates of residual adenoma? So when we talk about cold snare EMR, we're going to talk about assessment. We're going to talk about instrumentation, and I'm going to give you a little bit of what I do personally. We're going to talk about injection, piecemeal resection. Again, you have to look at margins. It doesn't matter if you're using hot or cold, margins are key. And then closure, not, right? We're kidding. You do not have to close these lesions unless you take a very large one out and you're going to go on anticoagulation. You really don't have to close anything that you remove with cold snare. Now this is very important. It was mentioned by Dr. Cahi. You know, know the NICE classification. And also know that the lesions most amenable to cold snare approach are the serrated polyps. And again, know what they look like. You can see that they're lighter than the surrounding tissue. I think we all encounter them, they have the mucous cap. These are clear-cut, the polyps we want to remove. This is another very familiar slide, basically saying if we think there's any chance of invasion, don't do piecemeal. You want to take it in one piece, or you want to send it to surgery. So again, these are important points for both cold and hot. Another familiar slide, know your PARIS classification. And in addition to serrated polyps, if you're going to remove adenomatous polyps using cold snare, you're going to remove those that are minimally or slightly elevated. So the 2A PARIS classification polyps. So keep that in mind. So when you're going to do the procedure, you do use a cap, okay. This allows you to look around folds. It allows you to use traction. Control of bleeding, probably less likely because the bleeding with cold snare is a little bit kind of like hamburger meat, it's diffuse. And then endoscopic stabilization. So again, always use a cap. I think it's key. You do want submucosal injection available. I think it was mentioned prior to that, it accentuates the margins of the polyp. And when you lift it, it's sometimes easier to grasp. Now if you put too much agent, sometimes it makes it a little bit more difficult. Select the correct snare, you have to do this. We do know that the cold snares are thinner wires. And this allows you to cut through tissue, okay. And we have data from GIE 2015 that the resection rates were better with dedicated cold snares. So do not use those that are used for hot snare and improvise because you took a hot snare off a polyp and you want to use it for cost savings. So keep that in mind. And remember, you don't need thermal therapy. You don't need clips. And you don't need tissue approximators. So smaller polyps, we talked about this. We don't need to go through this again. But again, if you're going to use biopsy forceps, you're going to use a jumbo biopsy forceps for very small polyps. And then cold snares, obviously for any polyp less than 9 millimeters, recommended by the U.S. Multi-Society Task Force. Now key concept of removing in cold or any polyp is you want to position the polyp at 5 or 6 o'clock, okay. This gives you the best position. You also want to remember if there's a pool in the way, change the patient's position so that you can actually see the lesion. Keep the scope as straight as possible so you have the most control. Position the snare above the polyp, proximally pull back and then tip down to put the snare onto the polyp base. Push out the snare catheter towards the polyp base as the assistant is closing. And you want 2 to 3 millimeter margins. This is basic, but I think it's important. You've got it in the 5 or 6 o'clock position. What you're doing is you're suctioning the lumen. And then you want those margins, right. You want 2 to 3 millimeter margins because you don't want recurrence because that is the problem with biopsy forceps, okay. And then what I do is I'll bring it in, you see a little snag of tissue. If there's any question, just grab that. Just take the snare and go over that. The 10 to 19 millimeter lesions again were mentioned. So if you've got a pedunculated adenoma, you're going to use hot cautery. If you have a non-pedunculated less than 2 centimeters, you're going to use cold or hot. Any serrated lesion you can really consider cold. And again, this is the whole concept of the cold revolution. And Dr. Rex's data was mentioned. Now in terms of injection, okay, I do do injection. And there are various techniques that have been described. What I like to do is I use a little bit, especially if it's a large lesion, I'll use 1 in 100,000 epinephrine in one injection. So I'll do that first. And then this is a small lesion, but this is for demonstration. And then if you have, then after I get that epinephrine in there, then I'll go ahead and inject the dye. And again, the reason being is sometimes you'll get diffuse bleeding with cold snare polypectomy or cold EMR. And that sometimes will allow visibility to be better. So when you're doing resection, okay, again you want a cold-specific snare. You do that. You do not use one that's not. And you don't want that rim of tissue. You can see right there I have a little, sorry, a bit of tissue and island there. Don't want that. So you're going to have to overlap like we're doing there, okay. You want to see some of the submucosa and you want to overlap with the sessile tissue. If there's any question at all, there is no real increased risk in taking out more margin with this cold technique. So not quite sure whether that mucosa is abnormal. Maybe, maybe not. Sometimes right there you can see there probably is some serrated polyp left. So you keep taking it. Again, this takes very little time. And so this is a big do. You really, really need to go ahead and look, overlap, inject. And again, you've got the polyp at the 5 to 6 o'clock position. That is the ideal position. Now do inspect the margins. I think this was adequately addressed. But look at that. Take your, you know, your snare. I use it. You look around, you know. And if there's any question, take it out. It's okay to extend the resection. And do not close. So that's a don't for cold snare polypectomy. So cases that I think are best for cold EMR, SSPs, we've talked about this. And then 2A adenomas, which are in locations where hemostasis or closure might be difficult or in patients who are a high risk. And it would be best to avoid a complication. And you can see a 50-year-old with a 40-millimeter SSP in the transverse colon or an 80-year-old diabetic with oxygen-dependent COPD who has a 30-millimeter adenoma in the cecum. Like that never happens, right, in practice. So don't, this is another don't, and this is for all polyps. If you're not going to remove the polyp and you're going to refer the patient, do not inject into the polyp base. Do not biopsy the polyp. And do not partially resect. We know that this causes fibrosis and will make any technique after that much more difficult. And a predictor of failed subsequent EMR is prior resection attempt. So please keep this in mind. So this is a quiz. You do or don't remove by cold technique? Do or no? No. Right. Do or don't? Don't. Right. Because it's kind of, it's depressed in the middle. Do or don't? Yeah. Perfect. So I think after these two lectures we've honed that in. Now let's talk a little bit about adverse events and recurrence. You know the cold revolution, I think we've emphasized this. This is data from a little bit older of both colon polyps as well as duodenal adenomas. This technique I do use in duodenal adenomas. So you see no adverse events in cold SNARE groups. This is a meta-analysis from 2023 of over 7,000 polyps. And these are non-pedunculated adenomas and serrated lesions of 5 to 20 millimeters. And the limitations are, again, with randomized controlled trials, or I'm sorry, meta-analyses, they're as good as the data that you input into them. At least this one is a bunch of randomized controlled trials. But they varied in terms of the approach to cold and hot EMR. And there was also variability on the definitions of complete histologic resection and recurrence. And what they saw, complete histologic resection favored hot SNARE. In terms of recurrence, it favored hot SNARE. But again, like we talked about before, total procedure time was less with cold, as was delayed bleeding. Another randomized controlled trial, I'm sorry, meta-analysis. This one, though, did not include just randomized controlled trials. Again, the quality of the meta-analysis, just because something's a meta-analysis doesn't make it necessarily a good study. So just look at what they've included in there. And they've included nine retrospective cohort studies, two prospective cohort studies, and one retrospective case control of over 27,000 polyps, all types serrated at notice. And again, there was a variability in how they removed them. And they saw that delayed bleeding, again, less. You see the common theme, less with cold. In terms of complete resection, there was no clear winner. So again, we need to think about these things. And we need better trials. So we have ongoing trials here. You can look at this. And these are the trial registration numbers. And we look forward to this data. And again, I don't think we have to exhaust this. Less than 9 millimeters cold SNARE, 10 to 19 cold or hot, greater than 20 EMR, non-polypoid, non-pedunculated polyps. If it's an SSP, you're going to cold. If it's an adenoma, hot's preferred. Now, not so fast, right? So I think Dr. Cahi mentioned this study in gut, where they looked at large non-polypoid, non-pedunculated adenomatous polyps. And not to belabor it, the bottom line is that recurrence at six months was better with hot, so less common. And then in terms of clinically significant post-EMR bleeding, it was less with cold. So we get the same theme, right? So you're kind of choosing, you know, can we do a better job with technique in order to, for the large polyps, in order for us to use it instead of hot? Because literally, the adverse event rate is much lower. Again, in concepts overlapping with the snare, raise the polyp, look at the margins. These are all dos that will allow you to completely remove the polyp. So the take-home points are dos with the cold technique. Use as CAP. Inspect the margins. It's appropriate for all non-pedunculated lesions less than 10 millimeters. Consider for non-polypoid adenomatous lesions measuring 10 to 19 millimeters in all SSPs. Regardless of size, don't, with the cold technique, use it for bulky or pedunculated adenomatous lesions. How many of people have actually gotten stuck on the lesion? So yeah, it gets stuck. And so one thing I mentioned to do, my technician, is straighten out. Straighten out the snare catheter. You want to straighten out your scope. And sometimes you can gently pull the polyp and have it hit the nose of the scope. And if that doesn't work, you can open the polyp a little bit and close again because it's that submucosal kind of fiber. And then don't routinely close the defect. And remember, cold EMR may have increased rates of endoscopically removable residual adenoma, especially in polyps greater than 2 centimeters. Doesn't mean you don't have to use it. Use it selectively as Dr. Akahi mentioned. Use it in patients who are frail and cannot survive an adverse event. One wonders why you need to take a polyp out in somebody like that. But nonetheless, we won't go there. And with that, I want to thank you. Unfortunately, every day we deal with procedures and you do have complications. And colonoscopy is one of the most commonly done procedures. Our next speaker needs no introduction in the field of endoscopy and colonoscopy. I think Doug, you might be the only past president of both the societies here that I know. There are others, Nalini, but I don't know if they're here. Thank you. Thanks, Nalini and Michelle and Irving for the invitation. And hi, everybody. So I'm going to try to make just some tips and suggestions about bleeding, perforation, and then incomplete resection, which I think is interesting to consider as an adverse event, avoiding these and treating them. Here are my disclosures. So we've heard a lot about people's techniques. So this summarizes my own approach to resection in the colorectum. Everything that's 10 millimeters and smaller, I currently take out with a cold sneer, except for the extremely rare lesion where there's a suspicion of cancer. Anytime there's any suspicion of cancer, you want to use electrocautery. So we see tons of lesions that I refer to as zero risk lesions. You have complete confidence that you're not going to get a reading of covert cancer from the pathologist. Everything three millimeters and smaller, I still would cold sneer. If you use cold forceps, it's okay. But then if the patient also has 4 to 10 millimeter lesions, you're using two devices. We've heard a lot of sentiment that we can take all the SSLs and HPs out now with cold resection. I will admit, and just to give you a little bit of sense of variation, I don't inject them all. Adenomas, if they're bulky or pedunculated in the 10 to 20 millimeter size range, they may warrant hot resection, electrocautery, but many of them can be removed cold if they're flat. And then for the adenomas greater than or equal to 20 millimeters, here's where there's some variability in technique. So cold resection, I would say still a consideration for granular homogeneous lesions in certain circumstances. And there are two issues really here. One is, are you going to use electrocautery? And then secondly, do you feel that the lesion needs to be resected on block instead of piecemeal? They're really two separate decisions. So with that in mind, we'll talk about these goals of preventing and treating bleeding, perforation, and then incomplete resection. So the first thing I want to discuss is using cutting current, endocut, or forced coagulation current when you're performing traditional EMR with a snare. So there are tons of people that still use endocut. And my question would be, what's the evidence for that? We have only one randomized controlled trial. And this trial used microprocessor-controlled electrosurgical units. And there was no risk of delayed hemorrhage with endocut versus forced coagulation current. But endocut caused more immediate bleeding. And all three of the perforations in the 900-patient study were in the endocut arm. And I would say from experience that you can go through muscle with no difficulty with endocut, whereas when you're using forced coagulation current, you'll tend to get stuck on it and reevaluate whether or not you should go through it. Now certainly we want to end up with a submucosal defect that doesn't look charred. It has this nice blue color. And we can achieve that with forced coagulation current partly by squeezing the snare really tightly before we hit the blue pedal. And then we'll increase the current density in the snare and come through the tissue really quickly. But I would just reevaluate whether endocut is really doing a lot of good based on the evidence that we have. Our recommendations currently for closure are, at least where the evidence is, are lesions proximal to the splenic flexure that are 20 millimeters or larger in size and which we removed with electrocautery. Really all three of those things. And the best studied technique is clip closure. And technique I think is important. You want the defect to be either in the down or the right endoscopic field. And you need to learn to manipulate tissue with the clip. Typically with the open clip, you take one arm of the clip and put it into the mucosa and bend the defect toward you. And then with a combination of pushing and a little bit of suction, you try to get that tissue to completely fill the jaws of the clip. And that's important for keeping the clips on because if they fall off, they're not going to be effective. Oftentimes we're approaching the defect when it's in the five or six o'clock field. And usually we want the clip oriented in the up-down direction. And we're going to take the bottom prong of the clip and push down with the scope. And then again with suction, try to turn the defect toward us so that we can fill the jaws of the clip. Later on, we can actually go over the top of the clips, bend the clips down, and use that manipulation to get more clips in place. So what do we do with very large defects? Well, in the past, what we would do is take clips and just put them right across the submucosa. That's what you would do if you had a perforation. You would put the clips right in the submucosa. There's no problem with that. And then once you've drawn the edges together, you can see these clips coming out of the defect they were put in the submucosa. And these are placed mucosa to mucosa. But we don't have to do that as much anymore because we have a couple of these closure clips. They're made for closure. So this is the Boston Scientific clip, and we're grabbing here one side of the defect, moving it over to the other side, and then reopening and closing. And what we tend to do more often as we're approaching toward the bottom is just open the clip with it oriented in the up-down direction and take the sharp jaws of the clip, stick them into the mucosa on the anal side of the defect, and then with the clip fairly close to the scope, drive the scope forward and get the normal mucosa on the sacral side of the clip. And that's the approach that we use most often with these clips. Here again, we're grabbing the normal mucosa. And so we're going to drive over the top of the defect and catch normal mucosa on the sacral side. And then we'd use standard clips to sort of fill in the gaps. Now pedunculated lesions, we heard that our guidelines recommend that we should do something to prevent delayed bleeding from pedunculated lesions. And loops are an option. I am anti-loop. I don't like detachable loops because I think the priority when you resect pedunculated polyps should be to get as far away from the head as possible. A rule that is now well established is that any time you've got bulk, pedunculated, sessile, a nodule in an otherwise flat lesion, it becomes very hard to predict the presence of covert cancer. So you're anticipating covert cancer, and you get as far away from the head as possible. If you put a loop on, that loop will force you up the stalk, and occasionally you'll cut through a cancer and then have to recommend adjuvant surgery. So cut off, and use forced coagulation current. If you use forced coagulation current, you'll almost never get an immediate hemorrhage. I bet I haven't seen one for over a decade from removing pedunculated polyps. Okay, now we have suturing also. So in the left colon, this is a defect in the descending colon. We can now close these defects, and we don't have randomized controlled evidence like we do for clips. With this through-the-scope suturing device, and you can also use this in the right colon. It's especially nice when the defect is draped over a fold and it's hard to approach the defect with clipping. Okay, treating active bleeding. The great majority of active bleeding during endoscopic resection can be treated with the snare tip. And I just remind you that any time you're using the snare tip, you want to switch the cautery over to soft coagulation current. It's a lower voltage current. It doesn't penetrate as much, and it's safer to use when you're using the tip of the snare. And I would say we can probably control more than 90% of even the arterial hemorrhages with just the snare tip, the same device. If you have faster bleeding, you need to have some kind of grasping device. This is faster bleeding and these are coagulation forceps. Again we're using them with soft coagulation current. And you can use hot forceps if you don't have them. They're a little bit I think more challenging to use because the teeth on the hot forceps. But you grab the bleeding point, apply soft current. So you want to have these tools available to you in the unit. Reducing incomplete resection. And I don't want to repeat what Vanessa demonstrated beautifully, but I think the keys to complete resection when you're using cold EMR are to overlap the snare with the submucosal defect and the outside margin. And she demonstrated that really beautifully. And the other part is you need to stay close enough to the lesion and push hard enough on it that you see the serrated mucosa actually coming up through the snare. These things are very loosely attached to the underlying tissue. They separate very easily, but you still want to push deeply enough that you're cutting clearly through the submucosa. Biggest difference between cold snaring and hot snaring is that cold snaring cuts more superficially. So you've got to get down into the submucosa to get a complete resection. Okay, here's an adenoma that's maybe 13 or 14 millimeters. And I would consider this a zero risk lesion. I wouldn't use cold resection if I had any concern about the presence of cancer. But it's too big for a 10 millimeter cold snare. So the key is to get a wide margin on one side or one end, and then the same as we were doing with serrated lesions, overlap. Overlap the margin and overlap the submucosal defect that you've created. In our experience, that's very effective. When we're doing conventional EMR and we're trying to reduce recurrence, anytime we have visible tissue that resists snaring, we cannot use ablation anymore. So the argon plasma coagulator has almost no role anymore in resection. So here we're using an avulsion. You can do it either hot or cold. But if they have tissue that resists snaring, you have to find a tool that is resective. And then the final step, which has been discussed, is the snare tip soft coagulation therapy of the margin. And this reduces the recurrence rate by 75 to 80%. If we really get the lesion down completely into the submucosa, we resect all of the lesion, all of the muscularis mucosa, everything is resected. And then we aggressively burn the margin. We can get the recurrence rates down below 5% after piecemeal resection. When I see people doing this, the most common error that I see is they're not aggressive enough about it. You want to get 100% of the margin, and you want to fry it. You want to absolutely fry it. The idea is that the recurrences come in, for the most part, from the edge, and you need to aggressively burn that margin and keep going until you've got every nook and cranny taken care of. So managing incomplete resection. So in referral centers, I would say, oh, I want to go back. Can I go back? Yeah. So in referral centers, about 25% of the lesions that are referred to me have been previously partly resected. And perhaps the most important message is that if you have a lesion that you stop the resection of, don't send that patient to surgery, because there's going to be somebody around who can effectively resect it. But this would be a reason that I would tend to use electrocautery. I don't think cold resection works well when lesions have been partly resected. Plus this lesion is bulky. So there's an area of scarring down here where the referring doctor has removed part of it, and we're going to use avulsion basically to strip all of that off. But in our experience, we can get success rates, recurrence rates that are as low as the set of lesions that are referred without previous resection. So I think the key thing is don't send these patients to surgery if you can't get it out. And probably don't try it twice. If you've had to stop in the middle of a resection, probably that's a lesion that you should refer. Because I will tell you that we basically, people that do this a lot, we never stop in the middle of a resection except in the rare case where we discover a cancer that wasn't visible on the initial resection. This is hot avulsion. We grab the tissue, stretch it out, and you can see that we can resect here in the same plane that we were snaring at in the top part of the lesion. So this is a very large, granular, homogeneous adenoma. And this might be the remaining lesion that's a candidate for cold resection among the large non-pedunculated adenomas. I think there are several things that might drive you to remove this cold. One is your personal tolerance for complications. Where you live. Do you live in the big city or do you live in a small town where everybody's going to hear about it when you have a delayed bleed in the high school football coach? How far is the patient from your center? How elderly are they? What are their comorbidities? Can they tolerate a complication? And to some extent, and this is a pretty massive lesion, it's a question of can you close it when you're done? So this is a very large, defect-removed cold. And you can just sort of anticipate that we're going to have a recurrence because we used cold resection. There's going to be some part of this that we didn't get deep enough on. So here's the lesion six months later. These giant lesions always contract to these very small scars at follow-up. And that part of the scar is okay, but there is the recurrence. So if you're going to do this a lot and you're going to follow up your own patients, you need to be good at dealing with recurrences. And there are a lot of different ways to do it. I typically just take these off without injecting, with a hot sneer. If they're very flat with a volusion, forceps burn up around the margin and then close it. But I think the key thing is that if you're going to go cold on large non-penunculated adenomas, you're going to have high recurrence rates. You want a patient that is really engaged. You feel comfortable that they're going to come back and you want to feel comfortable that you can deal with the recurrences. Because we haven't injected, we usually will close these resection sites because you could have a type two muscle injury, a muscle injury where you can't really identify it. Prevention of perforation. I want to mention underwater resection because underwater resection has a very good track record for perforation. And you can see we're floating this non-granular flat elevated lesion up. I find that these are the very best candidates for underwater resection. They're very thin and if you inject them, they get big and they get even thinner. And sometimes they're harder to sneer. But they're very nice for underwater resection. You can tell there's a tattoo here and you can see the tattooed submucosa here. But keep underwater in mind because it has had a very low rate of perforation. When we're doing conventional hot EMR, we have the advantage that we don't have underwater and that we've stained the submucosa with contrast. And that allows us to see muscle injury. When you get these thick bands, they're usually thick parallel bands, that's type three muscle injury. The muscle is cut and you have to recognize that and repair it, close it up with clips or there will be a delayed perforation. So delayed perforations have become extremely rare after EMR, after modern EMR because we now can recognize the muscle injuries and repair them. And here is a specimen. This is from a different one. That's the target sign. Those parallel bands of muscle in the defect that you see endoscopically, people also call that the target sign. And then treatment of perforation. So this is a big serrated lesion in the right colon that as part of a trial I was removing with electrocautery. And this is a not very big snare and it's being done with endocut. And I don't have very much tissue here, but I pop this muscle open. When this happens, it's always the time I'm least expecting it that it occurs and the times I'm really sort of afraid it almost never does, that's a clear hole there. So when this occurs, one of the first things that you want to do is start monitoring the patient's abdomen to make sure that they're not going to get distended. And if there's not a lot of fluid around that is not going to go out the hole, you can finish the resection. So you can see here that we finished cleaning up the edges of this thing. And then you want to close it. And I would advise in general, don't leave the area to get an over-the-scope clip because you risk stuff going out the hole. If you see stuff going out the hole, that's the difference between fever, elevated white count, and when nothing goes out the hole, the patient is essentially asymptomatic. I would still admit this patient overnight and give them antibiotics and watch them for a day or two. We typically would start the clipping outside of the defect, just at the edge of it, and then put the clips very closely together all the way across and past the defect, hemostatic clips. And this is very effective in treating perforations from EMR, which are almost always very small and pretty easy to close. So we've talked about prevention and treatment of bleeding, minimizing recurrences and treating them when they occur, and a couple of tips about prevention and treatment of perforation. Thank you. All right. The next speaker also does not need much introduction. It's Dr. Asma Shaukat, who has written all the ASGE guidelines along with Dr. Eggs. And she's actually going to do a video-based presentation on her top tips for polypectomy and how we can adopt them into routine practice. Thank you so much to the course directors, and what a wonderful course, and the audience for staying till the bitter end. So thank you so much. You notice that there wasn't a debate in this session because I think we're pretty established and pretty much agree on what we should be doing. So what I'll talk about is somewhat repeat of the other three speakers, but perhaps it's a good way to kind of summarize the session so you know that you definitely heard the same message in this session. So top five tips for polypectomy for the busy gastroenterologists, as we all have busy practices. And again, breaking it down very simply, so I'll give you just five quick tips and then maybe a sixth bonus one. So typical day, 68-year-old undergoing colonoscopy for an R-setting positive fit, and you encounter a polyp in the ascending colon as shown. So this isn't white light. Everything you've heard so far, so this might just be kind of a recap or a quiz. What is your approach? So what's your step number one? Well, step number one is inspection, as you heard from Drs. Ghahi and Shami. Critical aspect of the exam and resection strategy. And again, you've heard about the various classification system. And your key question here is, is there presence of deeper submucosal invasion and or malignancy, which will completely change your management? Again, I won't belabor this. In the two multi-study task force documents, again, you're going to want to morphologically classify it as well as trying to use, you know, these newer classification schemes that classify lateral spreading tumors, which could be a combination of the Paris classification. And then obviously you want to histologically characterize it for any type three features, because those are the ones you're going to want to leave alone or have a better plan or technique for. So again, when you're doing inspection, you can do white light, also narrowband imaging, near focus. Those are all great tools. So get in the habit of switching them on in our scopes. And then other scopes obviously have some parallel systems for inspection. Obviously pit pattern, you just heard the characteristics of the pit pattern and how it might help us think about the polyp and approach it. And what you obviously want to avoid or be very cautious about is if you see a non-granular surface, an area that's kind of smooth or pseudo-depressed, any redness, expansion, firmness, as you heard, or that chicken skin, and obviously the non-lifting sign. These tend to be more specific, not so sensitive. But when you do see them, you know, make sure you pay attention and have a high suspicion for submucosal invasion. So here's that same lesion. We did turn on NBI and near focus with our Olympus scope. And you can see it really helps us kind of characterize this lesion. And anybody notice in the near focus anything worrisome? So certainly there's that one central area which does look, and it certainly had firmness, it has some extra redness, and the capillary pattern looks different. So that would be one area we'd obviously want to know. The second tip, knowing your expertise. So only start a resection if you're confident you can do it. In some of our ASCs where the schedule runs on time and you have only 30 minutes, maybe not get into something that you can't finish. So can you resect it today? Also, if you want a second set of eyes, and we do this routinely, if you have that luxury, call a colleague who's comfortable with advanced resections, if available to review, or at least take a lot of pictures so you can then share with your colleague and discuss the case. Consent, did you consent the patient that there is a chance that this might be an EMR or something more complicated and the increased risk than a screening colonoscopy? And then you may wanna have kind of a standard for when you are just gonna do a tattoo placement and not attempt it that day, save it for a different day or a different endoscopist. Tattoo placement ideal, two to three separate sites, three to five centimeters distal to the lesion, ideally opposite walls. Describe the lesion and photo document it in your report. In our new quality indicator document for colonoscopy, we've emphasized increasing photo documentation of polyps, their morphology, histology, location, and even the snare or other things that you use, and then a picture afterwards. Submucosal fibrosis, if you inject too close to the lesion is always a concern, that makes resection much more difficult. And there was some debate whether you, are there areas where you don't need to tattoo, you can just describe. So perhaps in the cecum, ileocecal valve, or distal rectum, but again, have a pretty low threshold to tattoo. And now you're ready to resect. So say the polyp is 15 millimeters, it's in the ascending colon, and you determine there's no apparent submucosal invasion. So now you gotta pick a method, and you just heard some of the pros and cons about all these methods. So essentially, this is some of your, things in your armamentarium that you might wanna do. Cold snare polypectomy, vast majority of polyps can be removed. A conventional or hot EMR, a cold EMR, or an underwater EMR are all possibilities. Again, size and morphology really matters in how we plan and approach the polyp. And you just heard, anything less than five millimeters and six to nine cold snare polypectomy should be the standard. A non-pedunculated 10 to 19 millimeter polyp with no submucosal invasion of cancer. Again, both the US Multisite Task Force and the European Society Guidelines kinda say either cold or hot with or without submucosal injection. Non-pedunculated polyps, hot snare EMR, hopefully everybody agrees on that. And then anything pedunculated over 10 millimeters, again, only hot snare polypectomy. And you can see this nice flowchart in the document. We already heard about cold snare polypectomy, so I won't belabor that. But again, the emphasis should really be on the technique. So yes, cold snare polypectomy is effective, especially for complete resection of SSLs. But before we get too caught up in what snare to use, really think about the technique more so than the snare type. And with cold as opposed to hot, we wanna kinda press in and press down as opposed to tenting and pulling away. So again, you also heard about snare selection. You have multiple options, either stiff snares with braided wires, preferable for EMRs or N-block resections, or the thin wire that you should have. So ideally have a combination of both and then know which settings are ideal for which. We use a fair number of braided snares, even for cold, because we don't wanna use more than one snare per patient, but it could be very practice dependent. And again, having a dedicated cold snare, one that's available to you and one that you're comfortable using and knowing how it can benefit you, particularly when you start getting into not just SSLs, but any type two morphology lesions. Submucosal injection solutions, again, have something that you know is tried and true. We generally mix one cc saline and a 500 cc bag of normal saline kinda lasts all day and then gets replenished. Indigocarmin can be used, except it was in a shortage for a pretty long time. And then there's the proprietary submucosal agents, which have lately fallen out of favor due to issues with submucosal fibrosis and changes. But, and there's cost considerations there. So again, no one consensus, but have something that is your go-to and that you're comfortable with. And then in terms of techniques, you did hear about submucosal injection. You did hear that Dr. X doesn't quite often use it. So here we're kinda combining the techniques. So this is, you know, underwater, filling the lumen with water, seeing if this lesion kind of floats into the snare, which makes it much more easier. And again, you know, submucosal injection is a good idea. Here again, we're using the diluted methylene blue with normal saline. Again, people do use epi in this smaller lesion. It's really not necessary. And your technique really has, you wanna define the borders and have the lesion come towards you so that it's easy and it kind of floats into the snare. So really the injection should be on the two ends that bring it close to you. Try not to inject at the bottom that makes the polyp fall away from you. Or you could inject in the polyp also as a technique. And then you can see after we're done, compared to when we started, it kind of makes the polyp much more easy to see and hopefully put a snare around and take out cold. All right, cold EMR. Again, you saw multiple studies. I'll give you one of the largest meta-analysis with 16 studies on this. And again, as you heard, intraprocedural bleeding, and it's maybe a little higher, but that can be controlled. But delayed bleeding is extremely low and much lower than conventional EMR. And in this particular meta-analysis, there were no perforations. So you can see recurrence rates are still there, particularly for adenomas when the polyps get larger than 20 millimeters. But for SSLs, this seems to be an ideal strategy. So again, an important study. Cautery, you heard just now from Dr. Rex what he likes to use, mostly forced coag. Again, knowing the endosurgical unit that you have and being able to use it safely and in a matter that gets the job done is important. So this RCT actually randomized patients to either endocard or forced coag, and really there were no differences in serious adverse events or polyp recurrence at the first surveillance. So again, emphasizing the point that technique and what you're comfortable using and being able to use it well is perhaps the most important factor in choosing your electrocautery setting. And then I already talked about underwater EMR. So again, a great technique, something that you should all try and be very comfortable with. It comes in very handy, particularly for, it can make all the difference between complete and incomplete resection. So it's conventional insufflation with CO2, but distends the lumen, flattens the folds. So the idea is to suck out all the CO2 or gas and fill the lumen with water. The folds become more prominent because the involution of the mucosa, submucosa, and they actually float into the snare once the snare is placed on it. And a wonderful diagram by Dr. X that kind of explains the concept. So you fill the lumen with water, the lesion actually floats towards you and you want it away from the submucosa and definitely muscularis propria. So this can essentially give you a nice cushion. So you're not cutting deep into the submucosa, preventing delayed bleeding as well as risk of perforations. So again, you'd suction air, infuse water. It does require a good bowel prep. So make sure you clean that segment well, bring the polyp to the dependent portion where the fluid is pooling. And then sometimes you have to torque and crimp to grab a flat mucosa. The advantages is good visualization because the water actually gives you some extra optical zoom. It can be fast and efficient, particularly if you practice and become proficient at it. Requires less accessories, decreased cost, and larger pieces can be removed and blocked. So again, here's a case. We try to do this actually more than we probably need to, but it's a great training tool also for our trainees. So again, we fill the lumen with water. As you can see, the lesion kind of floated almost into the snare, making it much more easier. Obviously we're doing piecemeal, but again, it's much easier to grab larger portions. And then the concern for going too deep is much less. And we can kind of work through this area. Again, the field also becomes a little more clear and you can see the focus is much higher than without the lumen filled with water. So it's easier to notice and appreciate the architecture of the mucosa. So it's also easier to continue to go around the edges till we're sure that we got everything, including the really, really small pieces. So again, getting everything in the edges is really important. And then inspecting it underwater also makes sense. All right, the next step is to treat the edges. What should you use? Soft tip, soft coag, or APC? Again, according to at least this randomized control trial that either used soft tip coag, APC, or no margin treatment, you can see the differences. So clearly with APC and soft tip, soft coagulation, there was much less recurrence at first surveillance compared to no treatment. So the idea isn't to burn visible tissue. The idea is to remove any visible tissue and then go over the margin with either APC or snare tip. So this should be something you should all be doing in your practice. So again, just a quick video of treating the edges here. So lesion that we removed, EMR. Again, I like using methylene blue. I think it really gives us a nice base. And you can see, at least visually, we couldn't appreciate any residual tissue left. And that's the time to either use APC or soft tip, soft coag, because we usually use snare tip because, again, it's already there, much more efficient and practical. All right, and Dr. X had a wonderful demonstration of this. The last tip is inspecting what you've done, looking at your handiwork, and seeing if it needs clips or not. Again, there's different guidelines on, or guidance in when to use clips, but lesions larger than 20 millimeters, in particular, anytime you see a target sign. So again, having a pretty low threshold for using clips, and the technique, as Dr. Rex described, starting at the edges and trying to go after a zip closure. And then my final tip, follow the surveillance guidelines, as laid out in the multi-study task force guideline. Your polypectomy, you should be confident enough that you can actually feel comfortable that you can actually feel comfortable giving patients a surveillance interval as recommended by guideline. This is also a quality indicator for many of the colonoscopy registries. So for adenomas, 10 millimeter or larger, we would bring them back in three years. For adenomas with high-grade dysplasia, that's completely removed and you're confident. Then it's also three years. Only when you get into piecemeal resection, or lesions 20 millimeters or larger, then you'd wanna bring them at a shorter interval to look for any residual tissue. So again, being confident in your polypectomy helps you adhere to the surveillance guidelines. So Kohl's-Nair polypectomy is preferred method for polyps smaller than 10 millimeters. It's safe and effective for polyps 10 to 19. Lesion assessment and characterization is really appropriate for treatment. Underwater EMR is a valuable technique. I don't think we use it enough. So that's something we should be using much more. Knowing your limitations and then following appropriate surveillance intervals after you've done an effective polypectomy. Thank you so much. Here, Dr. Shaukat, and if I can have Dr. Kahi, Dr. Shami, and Dr. Rex come up to the stage. While you're settling down, what is the soft coax setting that you use for EMR margins? Effect five, 80 watts. Oh, wait, I mean. Effect five. Five to eight. Effect five, 80 watts. Effect five, 80 watts. Four or five, whatever gives you a nice burn. Asma, I'm gonna give you a hard time. You didn't burn that edge enough. That's why I cut the video clip early, because I knew you'd pick up on that. So I'm gonna ask you, Doug, again, because you have a paper on it. What do you do for retained clips that fall off? What do I do for retained clips? So you put clips and you go back for colonoscopies. They're still there. What do you do with them? I'm sorry, that's loud. Nothing. So the only time that you need to remove a clip is if there is polyp tissue that is growing around the base of it, or it's otherwise interfering with the resection of a residual polyp or a recurrence. So, and we almost never see that. Now, you will see, oftentimes, a mound of granulation tissue around the base of the clip. But you can just leave that alone. There's nothing wrong with it. It may be gone at the next follow-up. And if there is residual polyp, then you wanna take a snare and get underneath it and just resect underneath the polyp. I've done that a number of times, and it's safe to do that. So, Dr. Kahe, I know there was a slide there that said greater than 20 millimeters, you bring them back in one year. And the question here is, what do you do for a piecemeal polypectomy on a medium-sized adenoma? I presume they're saying 10 to 15 millimeters, that they've done piecemeal. You really don't need to do piecemeal polypectomy on a polyps in that size range. If you're doing two or three passes, doesn't mean you have to bring the patient back at six months like you would do for a 20 millimeter or larger polyp. I mean, if you're doing it cold, though, Charles, you are doing it piecemeal, right? Because the snares are only nine or 10 millimeters in size. But I mean, I agree with you totally that there's way too much people being brought back at six months or a year for 10 to 20 millimeter polyps. And our guidelines only say that you need to bring patients back for 20 millimeter and larger non-pedunculated piecemeal resections. Yeah, so smaller piecemeal is three years. So, one of the questions, and this is something that I think I know the answer to, because I think, Doug, you've talked about this before. When you do cold snare polypectomy and you get that little whitish piece of tissue in the middle, I think you've said leave that. That's submucosa, right? Yeah, Vanessa, you wanna talk about that? Oh, you mean that little tail? Yeah. Oh, yeah. That's a normal finding. Yeah, absolutely not. It's only when you see an island of polyp that you go after it. But yeah, that's normal submucosa. It's called a submucosal cord. Yeah. And it looks funny, and our fellows always get very psyched about trying to take it out. But just leave it alone. It's actually just a band of submucosal fibers. Yeah, that's exactly right. And it usually occurs when you've either really closed the snare really tight or mechanically pulled it off. If you mechanically pull it off, you'll always get a cord. If you're there for a while and you use the water jet, you can actually see it slowly spread back out. It's just submucosal fibers. So we have four experts here. Just raise your hands. How many of you use routinely caps for your colonoscopy? Routinely or for resections? No, just routine colonoscopies. I actually do. I prefer endocuff. Same here. Endocuff vision, and I use the cap only when I know I'm going into takeout to do an EMR. Nalini, I use the cuff to detect, the cap to resect. That's kind of the base. To be honest, I don't do screening, so. Okay, fair enough. I guess maybe that's why. So why are there zero perforations with cold snare? I think Doug mentioned it. You're not going as deep, so you're in the more superficial submucosa, A. B, much easier to cut through the muscle with heat. You're really not going to be able to cut through. If you've got muscle in the off chance, you're not gonna be able to close that snare and cut through the tissue. So it's really easy and simple. And it's not zero, though. It's just extremely rare. You can do it. You gotta try really hard, but you can do it. Have you done it? I have. I did it driving into a lesion with the scope. I was forcing into the scope in the transverse colon. The transverse colon and the cecum are the two parts of the colon most susceptible to perforation, and I cut right through the whole thing. But again, easy clip closure. So Doug, there's a specific question for you. What is the avulsion setting of the generator? So the avulsion setting has changed, and I do use EndoCut for it now. And I use pure cutting current. So when you're using forceps, you want to be on EndoCut I rather than EndoCut Q. And I have it on the one, four, one setting. So that first number is the most important because that's the coagulation level. And that varies from one to four on an Erby. And so it's just on one. So one, four, one. And then you, it's very important, I think, if you're doing hot avulsion, that when you put the forceps out, you don't overlap a lot of submucosa. You want to get over the small amount of tissue that you're trying to get. But you don't want to grab a huge amount of tissue, especially if you're right on a fold. The muscle comes up very close to the mucosa right underneath the folds. So you overlap a little bit, then you tent away, and you just tap the yellow pedal. Tap, tap. And as you see, as you tap, you'll see the tissue peel off. Again, any questions from the audience? As I said, not everybody needs to text, but if you want to stand up and ask a question, please feel free. Do we have other questions? No, we're up now, we're five to three. All right, I'd like to thank all the speakers for a great session, very practical, very useful. I would like to thank all of you on behalf of ASGE for attending this course. You've been a great audience and participants. The questions were very engaging. And as a reminder, please access the GI Leap and complete the course evaluation as soon as you can. It'll help us develop more programs and plan for the next course better, so the topics are all relevant. And your feedback is greatly appreciated, and please write the comments. Also, please make sure you fill out the CME and the mock credits so you can get them, and they're all available through the ASGE's GI Leap. And the next year, we are having the AGA and ASGE postgraduate course that will be on May 3rd to 4th, 2025. It's the first time that we will be doing this at San Diego. I would also like to have a shout out for our ASGE staff who worked very hard in putting this program together. I see Marilyn and Vanessa here, and the rest of you who are there. Hard to mention all the names. It takes a lot of effort to put this program together. And thanks again.

colon cancer

polypectomy

Dr. Charles Kahi

Paris classification

NICE classification

cold snare polypectomy

Dr. Vanessa Shami

bleeding prevention

serrated lesions

Dr. Doug Rex

Dr. Asma Shaukat

colonoscopy safety