Chesire, you want to just start off with this. So tell us about Chesire, the ESG guidelines on bowel preparation and, you know, standard volume, low volume, high volume, how do we go from there? And good to see, by the way, that you're wearing the Kansas City Chiefs, you know, jersey. So, you know, you're a winner already, as far as I'm concerned. Yeah, yes, Pratik. So here in Europe, we updated our guideline in 2019. And we were very ambitious at that time, because we put 90% as the acceptable rate of adequate bowel prep as a quality indicator. While doing this meta-analysis, you may remember that we did, sorry, while doing this guideline, we did a meta-analysis between high volume and low volume. And we showed equal efficacy between the two, while low volume bowel prep were better tolerated. For this reason, we gave an equivalent recommendation to use low volume, as well as high volume, differently from our previous guideline, where high volume were to be preferred. So now, here in Europe, low volume bowel prep are equally recommended and are somewhat dominating the bowel prep market. Okay. Tania and Joe, are you on? Yeah, I'm here, right. Okay. So, Joe, what's your practice? And, you know, obviously, the guidelines recommend and we use a split bowel prep, which should be the standard, which hopefully everybody online is practicing that already. So what are some of your standard instructions, Joe, which go out to the patients? And again, just tell us about the patient journey. Is there a nurse who calls them, reminders, et cetera? Because we understand how critical bowel preps are. I mean, we can use the CAPS, we can use AI, et cetera. But if the bowel prep's not good, all those tools are sort of worthless. So tell us about that. So a couple of things. One is, I just want to reiterate, you know, Chasari, Hassan, your guideline was very useful for us for, you know, looking at creating a new set of recommendations. But I just want to highlight the quality ACG slash ASGE guidelines just came out recently, in which we also set the expectation for bowel preparation to be 90% as well. So we have that benchmark, so raised from 85%. I think the recommendation for low volume for people that are not at risk for having poor bowel preparation, people that are not obese, not on opiates, and all the other predictors, the low volume, the two liter prep is what we recommend. A couple of things that we do is we have an interactive nurse call where the nurse tells them at what time, if they're going to have an afternoon colonoscopy or a morning, tells them what time that they need to take that second part of the prep. Also what to expect in terms of the effluent that they experience in terms of what they should be seeing, and the possibilities of doing other things in case that there is no, you know, if they don't get the result that they want. But essentially, I think the big take home is that 90% benchmark, as well as the low volume, the two liters, because as Chasari pointed out, there's been other meta-analyses that have demonstrated while there's a similar quality of bowel preparation, the tolerability is superior with the two liters. Tanya? Tanya, you've been sort of a leader in this field and, you know, pushing endoscopy quality. How do you track bowel preparation quality in your unit and, you know, what would be your some simple suggestions to our audience as to how they can track that and how important it is to do it? Thank you. Yes, it is important quality metric to measure for your unit. It's a pre-procedure quality indicator in the recent document, which reflects that what everyone has said, this is not a provider-specific only, it includes the nursing staff and the team in the pre-procedure area. I think measuring it is a first step and giving feedback to the pre-procedure team what the bowel preparation scores have been, if there had been a change in that for you to then regroup and see why. I do think that the 90% is a great goal. It also speaks, we were talking earlier about our ability within the procedure to improve a prep, but I can't emphasize enough and we do with our team that everything we do before the procedure is really going to help with efficiency as well as our own cognitive focus during the exam. We're not spending it washing, but we're spending it looking and removing. I do think that the low volume preps are preferred by patients and they are, in most cases, most patients are eligible, except for some of the limitations that Joe mentioned in terms of the potential factors for low volume. There are apps available now, those interactive apps that help. You could employ those in your group or your unit through text messaging apps, but the data shows again and again that a patient navigator, whether that be through an app or through a very dedicated nurse, in my practice at UCSF, most of these patients are motivated to take the prep because they know they may have something removed and so that is a motivator as opposed to screening. But at the same time, many of these patients have just had a colonoscopy, so the idea of repeating the prep is overwhelming to do that again and so that's there. But at the end of the day, I think it's a patient education navigator and we are making progress on those fronts. There are a few questions and I'll address a couple of them. I mean, again, this whole GLP thing has been sort of like a pain, so as to say, for endoscopy and being canceled and stuff. So there's one question about should we hold it for two to three weeks is the question and the answer is no. Recently, there has been a multi-society document which has come out from the GI societies in the US and the ASGE is coming out with its document as well, so I'd urge the attendees to go to that document and it walks you through a very nice algorithm about how GLPs should be withheld, if at all. And the bottom line is, if it's an urgent procedure, emergent procedure, just go ahead and do the procedure. Don't worry about the GLP issue. If it's a procedure which is elective, if the patient is asymptomatic, I mean, I think you know you're in good stead to go ahead again with the procedure and do that. So I just urge you to go to the document and do it. Cesare, the question I have for you is GLP and bowel prep. I mean, should we be, can your ESG guideline and Joe's recommendation of a low volume bowel prep, would it hold true for somebody who's on GLP as well or should we even bother with that? So here in Europe, we don't have the epidemic spreading of GLP-1 as apparently it was in the US. Some, honestly, we never had this problem. I guess that with a low volume bowel prep, even GLP-1 patients can be well prepped. Of course, if there is vomiting in the first dose, then everything is to be stopped. But I don't remember any case where a patient couldn't get at least 70 or 80 percent of the bowel prep. Okay, Joe? Yeah, and so the low volume, so if you look at the GLP, what they do is they just don't give you gastroparesis. They give you total bowel paresis. And the reason that that's a problem is that if it was just gastroparesis, it wouldn't interfere with liquids, right? Liquids are just empty. But it gives you total bowel paresis, so it gives you constipation and that sort of thing. So these people are at risk for poor bowel preparation. I think there are good data to support that. But the other issue is that sometimes because they do affect gastroparesis, they give you total bowel, so they'll give you stomach motility. They also have bezoars. And we don't talk about this too much, but I'm not a big fan of propofol. And the nurses will tell you, I like conscious sedation. We have one more time where I don't have 30-minute call-ins like I did at Stony Brook. I tend to have hour-long call-ins. And so I don't mind sedating people. But I do think of people with deep sedation, you do worry about stomach retention of food during deep sedation. But I'm more of the mindset that these GLP maybe should be held in patients. And we'll see what more data comes out. But one would think that they would do better with the low-volume prep, since there's less volume to go through. So I think more data are needed. So that's my opinion. And there's another question about a 7 a.m. procedure. Would you still do the split bowel prep? And the answer is yes. I mean, to the best of her ability, no matter what time of the day or night you're doing the procedure. I mean, you should try to do it again, except if it's a bleeder and you're doing a rapid purge or something for a diverticular bleed or something. You may not have the luxury of doing that. But besides that, yes, the answer is try to do that as much as possible. Tanya and Joe, also in the U.S., a lot of physicians, outpatients use this MiraLAX, Gatorade kind of a mix and stuff like that. Nothing that's supported by the multiple guidelines, both of you have written and stuff. So why is it still happening? And what can we do in order to make sure that people still use the bowel prep the way you guys are telling them to use it? Tanya, do you want to, and then I can as well. You go first, Joe. All right. So I don't want to just jump right in. But so the MiraLAX is, you have to be careful because it's not isotonic. So people, if they're going to, if they have to use that, I think the reason that people do use it because it's on the, you can get it over the counter, but you should be mixing with a sports drink so that you have the sodium in there. I think education is very important with respect to that, because I find that those preps are not adequate. People gravitate to them because it's easy to get them. But I think education, and this is hopefully where the guideline, our new guidelines that will be coming out soon, hopefully will help educate people. Pratik, can I make a point here? So what we are looking in Europe is that moving to low volume, not only increases the rate of adequate, but also the rate of excellent cleansing. That is eight, nine, according to Boston. And we now have up to 60% of patients are coming back with an excellent level of cleansing. So we are thinking of introducing somewhat a target for excellent level of cleansing, not only adequate. Okay. I think the other thing, in addition, oh, sorry, Pratik, go ahead. No, no, no, go ahead. I was going to say. I was more saying, in addition to the, I think the shift to low volume, which the data is showing is the low residue diet beforehand. So anything that we can change the patient's adherence to the instructions is really critical. And so I think that low residue diet has been shown and recommended even in the last U.S. Multistudy Task Force guideline to be implemented as opposed to these more restrictive clear liquids diets. And it also, in terms of, you were talking about gut motility, Joe, and the low residue diet, I think can keep that gut motility going as well to improve the bowel purge. So something also to introduce into your bowel preparation regimen. Okay, guys. So I think we have to go back to our cases, but thank you for a wonderful discussion. And I think the key message is that try as much as possible to have something which is more likely to improve the compliance of our patients. And low volume definitely seems like something that our patients would be more compliant with. And then this obviously would lead to a higher quality prep during the colonoscopy. So Doug, if you guys, or Megan, we'll go to you to present the next case and we'll be back in the room. So over to you for the case.

ESG guidelines

bowel preparation

split-dose prep

low-volume preparation

patient education