Hi, everybody. I'm Dr. John Guardiola. I am the other person at IU who takes out large colon polyps with Dr. Rex. I'm joined by one of our excellent techs, Big John. Dr. Greenwood is giving anesthesia for us, and then Jen is our nurse in the room. We're going to talk about a few different things, and Megan's going to tell us about this case first. So we've got a 60-year-old male underwent his first colonoscopy at an outside institution in August for positive coligard. There are multiple polyps left in the colon ranging from 10 to 30 millimeters, described as broad-based, but photos show some penunculated lesions, and no polyps were removed. So in this case, we're going to demonstrate optimal teaching techniques for resection of penunculated colon polyps. Thanks, Megan. So I have already cleared some of the polyps out of this gentleman. I've left about, I think, three polyps that I think are all good things for us to talk about. In the meanwhile, there was one question on whether non-academic center should have AI for polyp detection. What is your point here? Yeah, I mean, I looked at that question, and I think there was some issue there about the question saying that the machine has not learned over time, and for the last three years, it's showing the same results. And just sort of for clarification for everyone, the way the current AI devices that you will be acquiring, whether it's a lease, a purchase, whatever it is, is they're already pre-trained. So you can't just go in and have it improve with your data over time. So I think that's just something to keep in mind. And multiple randomized trials, including Chesray's meta-analysis in annals, have shown that it does significantly improve ADR. So John, we are back to you. We can see you. You've been ready to go. All right. Thank you, sir. So I've left about three polyps in here. One of them is this flatter adenoma here that's somewhere in the range between 10 and 19. And I think it's a good opportunity to discuss what we can do for polyps in this size range. You know, we have a lot of data for anything that's less than 10 millimeters in size that we should remove with a cold snare. And then we have a lot of data for things that are over 20 millimeters in size. But that middle range is something that we don't have a whole lot of data on. And I think it's interesting because the ESG guidelines, I think, recommend that we take these lesions out hot on block. But I think a lot of that is because of the limited amount of data that we have for this. But what I'm going to show here is just kind of taking this out with a cold snare and using the water jet to kind of expand the defect and basically assess the margins. So if John can open the snare for me. So while you're doing that, just quick question to you and Doug since Doug's in the room also is in lesions like this, when do you decide to inject rays so that you can see the margins much better than what you see just with just standard white light? When do you make that determination? I think a lot of that's more helpful for SSLs when we don't have, when the margins might be harder to see, close and cut. But for I think something like this, it was very obvious and the TXI actually helps a lot too. I don't know if Dr. Rex here wants to make any comments. No, I think, you know, that what the way we approach some of these flatter ones. So one of the decisions, right critique is, is injecting to see the margin. We do that with SSLs, especially that are bigger. I think we see so many of these that it's somewhat inefficient and there isn't really strong data that in the size range injection is critical. Maybe a little bit more in this, come back here, but John, there you go right there. And that, that injection is, is critical to the success and it requires more time. It's less efficient. It is going to have the cost of the injection catheter and get a good margin. I would just recut that whole thing. So Doug, just the point is that, I mean, if, because we have a lot of folks who are looking at this, figuring it out. So rather than leave tissue behind and deal with recurrence, you know, they could consider doing that if they're not really sure about the margins. Doug, I will have done it under water. I, because the, the Lisa will have been a bit more floppy and it would have been easier to cut it through. I think that's the, it's interesting, like the 10 to 19, just as John said, it's a little bit of a range that many different techniques are appropriate in. And I think that's demonstrated by the panelists views and what John's doing. One of the questions from the audience, Doug and John is on the bleeding. So, and you're demonstrating that well here, if you see bleeding, it can impair visibility, but you're using your water jet and then you're expanding the sub mucosa there to see your margin. So can you just comment on how you maintain visibility, even though there's bleeding with cold snare? I think the important thing is that the bleeding will almost always stop with just conservative techniques. So applying pressure with the water jet, you can apply direct pressure with the, with the scope like this and just wait a few seconds and just, and just be patient. I think with, you know, you can see now that the defect has expanded very well and the bleeding is slowing down. You know, I thought what I thought that last cut that John made was, was beautiful because I thought the left edge, he was initially a little bit superficial and he just put the snare down hard in the down direction and chopped out a really nice margin. And I think that defect, that defect looks great. And I think the risk of, you know, we, we showed in our own randomized trial for up to 15 millimeters with this technique that we basically didn't have any recurrences. So it hasn't been a, hasn't been a big issue, but I thought that was a, that's a really nice demonstration of getting a good margin on one side, because by definition that lesion is, is too big with a 10 millimeter snare to really get good margins and take it in one piece. So you get a good margin on one side, cut it, and then reset the snare so that you overlap your submucosal defect and the margin on the on the other side. John, what's your plan here? So I think that's a good thing for us to talk about here. So this is one of the smaller pedunculated polyps here, and then there's a much bigger one back here. But, you know, I think what would people do with this size polyp? This is not too big. This is a 10 millimeter snare will fit over this. And would anybody take this off cold? No. I mean, my preference still is to use hot for, you know, these kinds of pedunculated polyps. I mean, I think you could definitely remove it cold, but my preference is hot in this, you know, situation. I suspect, I suspect if you try to remove it cold that you may not, right? You may not because there may be enough tissue that you wouldn't be able to get through that. So I think anything that's larger than about a centimeter, I tend to go with hot right at the base. Sorry, sorry. So now regarding the risk of bleeding, I would go cold and then I would put a clip if the bleeding is too much. So I don't feel that pedunculated means that you cannot use cold in general. Yeah. I think we're going to try to take this one out cold and we're going to try to do some of our techniques about choking the stock and seeing if we can get it, get the bleeding under control without having to do a clip even. Open. Yeah. I mean, I think the issue is less with the bleeding, right? Rather than whether with cold, you'll be able to transect it or not. Right. I mean, I think that's the whole point and also Tanya, I mean, what's your sense? I mean, you see all the literature more on cold as we do it, but the recurrence rates tend to be much higher with the cold. So what's the panel sort of like thoughts around that as we keep on doing more and more cold, we'll get more recurrence rates. So where do we strike that balance? Yeah. I mean, I think, and here he's getting it on block. You can see it's becoming a schemic. He's, he's strangulating the vessel. Well, and to your point, will he be able to cut through that submucosal tissue? Because it's so much of it and it's so tough and then gathers and then you have to pull. So that I think in this particular point would be what, what may prompt you and then why cold versus hot. I think one thing that can be stressed too, is just interpreting the image here. Like John didn't think there was any chance of high-grade dysplasia, I'm assuming, or submucosal invasion. He's trying to get the stock as much as he can, but that can also influence perhaps your approach Pratik in terms of how many pieces you take with a cold or having a more on block hot for that. Yeah, Tony, but anyway, the point by Pratik is quite somewhat interesting. Why should cold work for 10 to 19 and not for 25 millimetres? So can we use cold for flat adenoma that are more than 10 or not? Or why to stop at 20 and not at 30 or 35? I think we should know more about the risk of recurrence after cold snaring of adenoma in general. It is showing, yeah, I think the more the literature comes, it does show the rates higher. It's something that you'll have to balance risk of recurrence versus feasibility of a technique perhaps with always having the image interpretation be the priority in any of the techniques that we choose. But I mean, really, if we're talking about recurrences, that's not really the lesion that we're talking about, right? The recurrence rates are higher for non-pedunculated lesions that are 20 millimetres and larger. That's really what the randomized controlled trials have been focused on. I don't know of any evidence that suggests if you take a 10 millimetre polyp out cold, that you're more likely to have a recurrence. And I don't see any empiric reason why it would be a higher, but I don't think there's any evidence that the recurrence rate is higher until we get to non-pedunculated lesions that are 20 millimetres or larger. Correct me if I'm wrong, but- No, I think that's what we were talking about, unfortunately, but it wasn't really pertinent to this case. Yeah. Right. I mean, I think that the point about the pedunculated polyps and cold snare is just the technique, right? I mean, is that if you can sometimes, if the stock's too big, you may not be able to transact it really well through, and that's why you may need hot snare. So just a message to our audiences that in those situations, it's okay to use hot snare. Yeah. I do think that there's an expanding literature on 10 millimetre and smaller pedunculated polyps that it's quite safe to remove them cold. And there are probably about five or six observational studies out there. There was a recent meta-analysis in JCG, and there's been a lot of variability about how often people put clips on the site. We tend to- you go ahead, John. We tend to only put clips on when there continues to be active bleeding. Actually, if we would remove it with electrocautery, because when you remove it with electrocautery, you're not really concerned about immediate bleeding. You're concerned about delayed bleeding. And so we clip all of those pretty much when we have larger pedunculated polyps. But with cold, we typically don't unless we've got an ongoing immediate bleed, which is maybe 5% of the time. What do you view, John, as the risk of cancer here in a lesion like this? This does have a risk of cancer in it. So that's why I'm trying to go all the way down as far as I can on the stalk. So some of the issue I'm having is that the stalk is very long, and then he's also coughing, which is why you see all the movement. I don't have that unsteady of hand. And so what we're doing here, it's a little bit different than other places might do, is that we're not going to use endo loop or any kind of prophylactic ligature device. We're trying to get all the way down on the stalk. We're going to cut through with forced coag. My good tech John here is squeezing the patient's butt, and I keep bumping into his hand, which is why you keep seeing the imaging change. But usually we try to get the lesion kind of laying away from us. Nice, nice, very nice. And then we get all the way down. And if John could start closing for me just slowly, you can see I'm all the way down on the base of this polyp. Quite a long stalk. I think everybody would use heat on this. I would never try to cut this cold. You know, the guideline for a stalk more than five millimeters or a head more than 20 to use heat. Good that the Indiana guys finally mentioned hot. The reason we're doing it this way is that our approach with these polyps is to, I'm going to come on through with, John's going to slowly let the burn go in, slowly come through, and we're gone. Can I ask the panel if any of you have kept the snare by himself rather than by the technician? We at IU, we have very good techs, and we usually don't have to deal with the snare. We really trust when they tell us, you know, how much tissue they have. I know other places are different though, but I would like to also just say that our goal here is to cut as far down on the stalk as possible to kind of maximize any oncologic margin, because if you were to leave a clips on the bottom or an endo loop on or some other ligature device, polyloop, as Olympus is one of our sponsors, we worry that you have to cut, you have to put that several millimeters maybe above the base, and then you put it several millimeters, you cut several millimeters above those, kind of risking a positive margin if in case that does have cancer in it, and there was kind of a gnarly kind of looking ulcer on the side of that polyp, so it might actually have at least high grade dysplasia in it. I take your point, but I will have injected some saline on the base, so in the case of bleeding, I will have tried to look back for my blap. Okay, interesting. We, I will tell you, we, I asked, I would ask what the, what the panel uses for, for current here. We, we tend to use forced coagulation current, and as long as you make good contact of the snare with the stalk, we just basically don't see these things bleed immediately. I, I mean having, I would guess it's been a couple of hundred big ones, and I have, I haven't seen one pump for, I'm not exaggerating, over a decade, so I think the key, I think some people use endocut, which I, I think is a, is a mistake on a pedunculated polyp, and you know, I think forced coag, as long as you have good contact and get a little bit of burn in before you start the transaction, you have an extremely low risk of an immediate hemorrhage, and so we would put the oncologic outcome above the risk of bleeding, just because we don't see it very much at all. Yeah, Doug, so I agree with you, but since we do underwater resection, with the forced coag, we had the two massive bleeding after resection of pedunculated polyp, so we use endocut, and I feel endocut is a good alternative until you are continuous on the pedal. The worst mistake with endocut, if you do pedal on, off, on, off, because then you cut a lot and you do not coagulate. If you do continuously, the effect is quite good, but having said that, I agree with you that without underwater forced coag is the way to go. Okay, all right. Doug, I just want to point out one thing that John's doing that, you know, probably everybody does anyway, is that he clipped before he started retrieving the polyp, and so a lot of times the fellows will want to retrieve that polyp. The most important thing is making sure you clip to prevent any bleeding. I mean, you guys use forced coag, which is the same thing that I do, and so the bleeding risk is going to be minimal anyway, but... I think also you want to be able to find the stalk. The base of it, if you leave a little bit of stalk, it can contract quite quickly, and so, yeah, I agree with you, Joe. Getting a clip on right away and then retrieving. I think this looks pretty good. Should we put a tattoo on here, John, do you think? I do not usually necessarily plan to put a tattoo, but I can. I guess the rationale for it would be because we have some concern that this polyp might have cancer in it, should we tattoo this? We are using a spot EX here is the thing that we use, and when we're marking for our own purposes, we usually will just mark on one side. The previous case, I was marking for surgery, and so we marked circumferentially, and one of the things I think is important is to always say where you put the tattoo in relationship to the defect. So, in this case, if John puts it to the left or distal or whatever, just to make it easier, and then we've got a tattoo in case we do need to mark it more completely for surgery. I think the chance of that is low, but I think it's not unreasonable to mark this particular lesion. We tend to not mark anything that's in the cecum, basically never mark there, don't mark very much in the rectum, and you can see we usually don't use the bleb technique. We use a 25-gauge needle most of the time just to make it easy to access the submucosa. Just put in a little bit. Nice picture there to document that. Hey, Doug, we're running a little behind. Can we go now to the commercial? Yeah, right away. Nice job, John. Nicely done. The mainstay of the technology is that it supports everybody doing endoscopy. A lot of the stuff that comes out just serves the small numbers of us that are doing significant advanced endoscopy work. There are far more diagnostic procedures that occur than any of the therapeutic stuff that some of the technology advances, so having a system that's got high-res, very good quality narrowband imaging or other sort of image modification technologies just means that those people doing general colonoscopy and general gastroscopy are more likely to have a successful experience in picking up the pathology they need to be finding. Absolutely, I mean the other example, day-to-day practice where it's really useful is when you're doing a large, sessile lesion EMR and you just get a little bit of ooze from the base of the polypectomy site, you can put the RDI on and you can just literally see the vessel, so it sort of makes utilisation of things like coag graspers or very accurate clipping completely different because it just changes the way that you're going to approach the bleeding sites because you can very accurately see where you need to treat. So I've never experienced it as a calming effect myself, but I would say that the advantage of being able to see the active bleeding point in a puddle of blood that you otherwise weren't able to see allows you to be more confident that you successfully achieved haemostasis. It's very straightforward. It gives you a complete visualisation of where the blood is coming from or where it might be coming from and allow you to treat it much more easily than under white light imaging.

colon polyps

cold snaring

AI in detection

polyp resection

margin assessment

advanced imaging