At Sabella Braintree, we're dedicated to our mission, as well as our GI community, to find new ways to set the bar on quality, as well as innovation, and continue to provide services to help you hit your goals. We recognize the common challenges that GIs are facing with strains on patient access, streamlining workflows, and the impact on cancellations with patients failing to reschedule. To address these challenges, we have revolutionized the way we're supporting the GI community through our NavGI 360 program. Through our collaborative efforts, we're now able to provide quality preps at a controlled cost to provide more convenient, low-cost care to patients, with an innovative patient navigation program to help drive adherence. This program is fueled by both SU-FLAME and SU-TAB, which are low-volume, split-dose preps that exceed the new quality guidelines of greater than 90%, which is now a 1C priority quality measure. Through our exclusive partnership with GiftHealthRx Partners, you simply send your script from your EMR to our pharmacy, in which we'll process the claim and then ship the prep, which includes your prep instructions, to the patient's home. Each patient will receive welcome messages, as well as enrollment reminders, to ensure they receive their prep in a timely manner. Eight days prior to the procedure, we engage the patient through our navigation program to provide procedure reminders, how-to videos, as well as information around the importance of getting screened. Each practice will also be equipped with a patient portal to allow your team to manage the patients in real time, to address any gaps for upcoming procedures, to ensure your endoscopy schedule stays full. Data shows that the navigation helps reduce cancellation, improves workflows, and can help support your CRC quality goals. This low-lift, high-yield program could be a great fit for your practice to help you achieve your goals. We love the opportunity to develop a long-term partnership and co-create value. If you'd love to see the full presentation and learn more about the references, please contact me so we can set up a brief virtual discovery meeting to learn more. Thank you very much. Hi, everybody. This is Doug Rex from Indianapolis. Welcome to the Glenn Lehman Endoscopy Suite. On behalf of IU and ASGE, we want to welcome you to this course on colonoscopy, a live course. I have with me in the room Ryan Carver, who's my tech, and Brittany Sprunger, who's my nurse, and Dr. Gardner is giving anesthesia. We're going to be using Propofol all morning long. We're going to do two cases that are relatively basic and then move to some advanced cases, but before we do that, I want to introduce the panelists. I got four of my favorite people in the whole world to help discuss the cases today. First of all, we're honored to have Prateek Sharma from the University of Kansas, who is the current president of the American Society for Gastrointestinal Endoscopy. I know a lot of people think of Prateek as a Barrett's guy, but in fact, he does a lot of colonoscopy and he has a lot of research experience in colonoscopy. Secondly, we have Tanya Kaltenbach from UCSF. Tanya is known to all of you from all of her presentations on polyp resection. She's the first author of the U.S. Multi-Society Task Force recommendations on polyp resection in the U.S. Third, we have my good friend, Cesare Hassan from Milan, Italy. So it's afternoon for Cesare right now. Cesare is probably the foremost thinker in colonoscopy and colorectal cancer prevention by colonoscopy in the world right now, and he's written many of the ESGE guidelines. So we're delighted to have Cesare with us. And then last but not at all least, we have Joe Anderson from Dartmouth. Joe is also a member of the U.S. Multi-Society Task Force, and he is somebody who has produced a lot of important publications, particularly those based on the New Hampshire Registry, and you've seen his papers in our journals. So delighted to have all you guys with us today. Are there some slides that you need to show right now, or can we get going with our presentation of the first case? We're going to go ahead and share the case slides. This is a 50-year-old woman who underwent first colonoscopy at an outside institution for indication of iron deficiency anemia in September. 41 adenomas were removed from multiple segments throughout the colon. Several were greater than or equal to one centimeter. All were tubular adenomas with one transverse colon lesion with focal hybrid dysplasia. Approximately 30 lesions left in place, primarily in the left colon. Larger lesions were removed by a referring physician, and there is no family history of colorectal cancer. Genetic testing was ordered and pending. So the teaching points on this case are insertion with endocuff. We're going to demonstrate high-quality examination technique, including right colon retroflexion. We're going to demonstrate TXI and demonstrate cold snaring technique. So we're going to go to the case. So when I'm doing routine colonoscopy, that is screening, surveillance, or diagnostic colonoscopy, I typically like to have something on the end of the scope. And most of the time, it is the endocuff vision. And so we're going to go ahead and get started with this case. I think the other possibility that some people like is just a simple cap or hood on the end of the scope. And this is the only insertion that we're actually going to show today. The rest of the time, we'll just be looking at specific lesions and removing them on camera. But I think that one of the things that possibly sort of holds back the use of the endocuff is concern about difficulties with insertion. And it's true that if the sigmoid is difficult, if there's a lot of diverticular disease, that you may have to push to get through or you may not be able to get through. And so under those circumstances, there's going to be... Doug, is there, do you routinely use something as an attachment on all your cases? Or was there anything specific about this case which made you use a distal tip attachment? Yeah. So great question is like, how would you pick? I tend to have something on the scope for pretty much all of my cases. The exception would be a really narrow sigmoid. When I'm doing EMR, I know I'm going in for a resection. I usually will put a cap on as opposed to an endocuff. In this particular case, because we're hoping to try to show some pretty routine things, I decided to use the cuff, which is what I would usually use for screening and surveillance. You can see we're passing a number of polyps here. Right. And we usually just use a transparent tip or a cap or stuff. I don't know for the rest of the panelists, what they do, Tanya, what's your sense or do you just go in without any attachment at all? I agree. For screening, surveillance, diagnostic, I use a cap for all of my procedures. For EMR specifically, I use the distal attachment device, the clearer one. In terms of the others, the screening, surveillance, I may use an endocuff or I may use a distal attachment. Some of it may depend on training the trainees in the sense of which one they've had more experience with. Some of it may be that sigmoid colon that Doug is talking about, but you can retroflex with this cap on. You can do anything really with endocuff. The main issue is the rigidity of it. If you are going to go through the tight sigmoid colon would be the only main caveat. But I think a cap for any is important. Doug, if you do without propofol, endocuff can increase the pain of the patient in the sigmoid colon. Is this your experience or is propofol something that simplifies the use of endocuff or you use it irrespective of the sedation? I agree with you that if you're doing unsedated, we tend to either do unsedated or propofol. We don't use in between, but I think it would apply for conscious sedation or moderate sedation with opioids and benzodiazepines. You have to push sometimes to get through the sigmoid. One of the points I wanted to make is that you actually, if you look at the studies, you actually insert faster with the endocuff on. I think it's because the endocuff actually catches folds. When you straighten the scope, you tend to not slip back more. We have found, our experience has been that we actually shorten our insertion times by about 30 seconds on average. I want to show you one thing here. I'm using an Olympus 1100 series scope. I want to tell you that I actually upper endoscoped this patient before we got on screen because of the number of polyps that she's had. I wanted to see, we have gotten genetic testing on her, but we don't have it back yet. I wanted to see if she had an upper GI tract pattern that looks like FAP. She actually did not. She had one tiny fundigland polyps, so she didn't have the usual fundigland polyp pattern. Her major papilla was perfectly normal, but she had about a 10 millimeter adenoma in the third portion of her duodenum. That was the only adenoma that I saw. I would say not a definite pattern of FAP, but just going through this colon, I think that this is looking like FAP. I wanted to show you, because the purpose of having a device on the end of the scope is so that we can pull these house scroll folds back like I'm doing right now and see what's behind them. I think that the endocuff, it's hard to beat its ability to straighten out folds, but I also have... Go ahead. Yes. It seemed to me that the endocuff itself is somewhat smaller than the diameter of the proximal colon. In order to stretch the fold, it seemed to me that you need to modify your way of withdrawal. For instance, now you are looking on one wall, then you need to go back and to look at the other wall. Can you confirm this? How do you withdraw with the endocuff in the proximal colon? Well, I would agree with that, Cesare, but I think that you want to do that anyway, right? Because even if you're not using it, you want to try to get between the house scroll folds. I agree that I think that the endocuff pulls the folds back more, and whereas the distal attachment does rely more on your torquing and dial tip deflection to get in between the folds, even though it's better than no cap. I agree with your point that you're a little straighter when you come back with the endocuff. Yeah. The other thing is that you're using the AI device, which has nicely picked up some of the diminutive polyps. Now, we can argue how important that is, but plus now you're using two techniques to improve your ADR, a distal attachment, as well as an AI device. I think there's been, what, Cesare, one randomized trial comparing a distal tip with AI versus just that, which showed increased ADR. And of course, I have to put in a plugin for the AI Institute of the ASGE. So Cesare, what are your thoughts? I feel that you are a bit sleepy now, Pratik, because I guess that there are three randomized trials showing the additional efficacy of endocuff over AI, because the problem is should we show the superiority of AI over endocuff or vice versa? I guess that AI is somewhat the standard now. So probably, I feel that endocuff helps AI. So what I want to show you was the look of the colon in TXI. So TXI is currently on, and this is a new modality available on the 1100 series scopes. And one of the things that I like about this is that it enhances both the texture and the color of the colon. I'm in white light, and now I'm flipping to TXI, and you can see these polyps kind of jump out at you when you switch to TXI. A little bit of pressure there, right? And compared to MBI, which has been our other form of electronic chromoendoscopy, the thing I like about TXI is that it's very comfortable to use. If we were going to switch over to narrow band imaging, and I can do that for a moment, you can see we have all this pink junk. It's not the world's greatest prep. There's a fair amount of mucus here. That's RDI. And now you can see white light, and then TXI. The fecal material is really not that problematic. And I think also it's close enough to white light that it's very comfortable to use. So I always examine the right colon twice, and I did the second exam there in the forward view. And you can see this is looking very much like FAP. But how do you guys feel about the double right colon examination? Dago, when you say two times, you mean one in retroflexion and one forward, correct? First in the forward, and then go back into the cecum, look at the cecum in the forward view a second time. Then I usually would go into retroflexion. You can get a cold snare. Terry, I think Joe had a comment. Joe? Yeah. So I agree with you, Doug. And what I'll do is I don't look retroflex. What I do is I do use the endocuff. When Pratik had asked about endocuff, I do use endocuff, and I can say why in my patient population it's a little bit easier to use. But I look twice in the right colon, I think most people do, and that's obviously a recommendation. But I don't do it in retroflex, and I can get a pretty good view with endocuff beyond the folds. Yeah. We actually published a series of looking in endocuff after looking in the forward view, and there still was a yield. But I agree with you, Joe. Now, Joe's at the VA. That's what you mean by your population? You feel like it's a little bit easier to do a right colon retroflexion? Or no, I'm sorry, to use, what are you saying exactly is different about men? Endocuff. Easy to use endocuff. Retroflexion is not always possible because you really need the scope to be straight. You need real column strength. But even with an adult scope, with the stiffener to the maximal number three, I still have trouble having enough column strength to retroflex. I think just the message is that you do something in the right colon twice, right? Either you do a forward view twice, or you do a forward view once and a retroflex view second. And that was supported by a nice meta-analysis, which showed that either way you would reduce your AMR, right? Or your adenoma misrate. Now, Doug, just on this case, the patient had a history of like 40 polyps or 41 polyps and they removed the larger one. What's your approach to patients with multiple polyps? Is there a number of polyps that you'll remove and then stop? Is there a time duration after which the colonoscopy has been X number of minutes that you'll say, okay, this patient needs to come back again? How do you do that in practice? Well, I think all those things come into play, Prateek. I mean, we sometimes will take out more than a hundred polyps in a session. In this particular case, I think that this is more than I really want. Now this is going to squeeze that a little bit, Ryan. This actually polyp might be a little bit pedunculated. It's maybe eight or nine, 10 millimeters, and we'll squeeze it just a little bit before we cut it cold. Go ahead, Ryan. And most of the time that will prevent bleeding. This is more open in the proximal colon than I really want, close, to remove or try to manage endoscopically. I think she should have surgery. And I will tell you that most of the time, even with a much heavier rectal, we're in the rectum right now, a much heavier rectal polyp burden than this. We will clear the rectum, mark it for surgery, and go ahead and cut, and then have the patient undergo a subtotal colectomy. So that's what I'm doing right now. We're trying to demonstrate here basic good cold snaring technique, which is move the lesion to the five o'clock position, capture, cut, that's actually already cut, but open. Capture a rim of normal tissue, closing. And so we have a rim of normal tissue, and then we cut through it. And so I think proper positioning, proper distance, these are incredibly important skills that transfer to more complex endoscopic resection. The final thing we're going to do here before we switch over is put a tattoo on the rectosigmoid where the patient will have surgery. And I won't go into all the advantages. You can take that, Ryan, grab the tattoo. I won't go into all the... Two points. First, do you feel that endoCAF is helping you? Secondly, what is the proportion of polyp that you retrieve after cold snare? Because according to Daniel Vorenten, we miss up to 20% of cold snare polyp in the moment of retrieval. Yeah, I think that number is way too high. And I think that we probably... And the goal, our guidelines say you should be able to get, we'll take the tattoo now, you should be able to get 95% of them back. So that's not our experience that we miss that many of them. I don't know what others think about that. I agree, Doug. So much of that is you cut the polyp properly, like Doug's showing, your accessory channels right there, and you suction the polyp right after you cut, just like Doug's showing. That number seems way too high. I think Cesare's point I think is well taken though, in the sense that when you start removing really one millimeter polyps, two millimeter polyps, you have to have a good technique in which you pull your snare back into the channel so as to say to retrieve it. But otherwise it may be difficult to retrieve it in non-expert hands. So not that we should stop doing cold snare polypectomy, but we should be cognizant that we are trying our best to retrieve all those polyps. Yeah, I agree, Prateek. And Heiko and I have a polyp registry. We collect upwards of 95%. And really what it takes is you really have to be assiduous and just very patient. I'm not a big fan of the syringe technique. I tend to leave my snare in if I have somebody with a lot of polyps. I leave my snare, I use an adult scope and you can suck around. What I'll do is I'll just fill the lumen with a lot of water and just suck, suck, suck. And I find that with patients, sometimes it takes 30 seconds, sometimes it takes a minute, but just persistent suctioning, you can get a large percentage of the polyps and it's important to get that. The other thing too is if you have an adequate margin, even two to three millimeter adenomas, you can be able to have, they're big enough after you snare them, you can see them in the trap. Okay. Cesare, there are some questions in the Q&A thing. Should we just all look at them one by one and do it? So while we're doing it, Doug, I'll just ask you a question. There's a question from the audience. What type of snare are you using? We're using a dedicated 10 millimeter cold snare. It's the Boston Captivator Cold. And so usually these dedicated snares are, are reduced and they're still braided snares, most of them, but they're, try that. Okay. I'm going to wrap up here in just a second as we finish this tattoo, full ML there, Ryan. So we've got nice, so we have a nice concentric ring of tattoos that it's going to mark the subtotal colectomy site. I'll just take a quick photograph. We've cleared the rectum. I think a good demonstration of TXI as well as cold snaring with a, with a dedicated snare. The most important thing about cold snaring is not the snare, but the accuracy of the, of the placement. Okay. We're going to switch over. Thank you guys so much. We're going to switch over to Dr. Guardiola in the next room.

NavGI 360

gastrointestinal challenges

patient navigation

colonoscopy techniques

endoscopic examination

polyp identification