Chesray, Joe, and Tanya relating to distal tip attachments, et cetera. And again, I think it's what we've seen is different people using different things. I mean, I can tell you our standard practice is to use a distal tip attachment and we just use a simple cap, a transparent cap. And specifically for patients that need, you know, a resection, I think the cap really helps. It stabilizes the mucosa. I don't think there's an issue about that. There was a question though, early on about trying to intubate the TI with an endocuff. I don't know if what your suggestions are on that, but it does make it a little bit tricky and difficult. Yeah. So, so I like the endocuff. You know, I started using a lot more when I did the XC trial for the, and, and, and I think that the key to the IC valve intubation is really taking out that air. I have no problem even with an endocuff because the endocuff you can go in, you know, the problem is pulling out, right? But that's the idea of it. But I have no problem. I suck out air. Air is your big enemy if you want to intubate the ileocecal valve. That and having enough column strength. Pediatric scope, I feel like there's so much looping that with the adult scope, even with endocuff, I have no problem. And by the way, I like the endocuff better than the cap, unless I'm going to have to resect a large polyp. I like the endocuff because of the fact that with the poor preps that we tend to have when I'm salvaging, it doesn't create a big mess. Everything gets stuck in the cap. So. Tanya, a question for you about malignant polyps and, you know, thank you for pointing out what those features are, because I think that's extremely important as we try to resect them. So in some of these polyps, we saw Doug injecting right into the center of the polyp and then on the sides and stuff. Is there a risk of malignant seeding if it's a malignant polyp and you're trying to do that? Yeah, I don't think I would inject through a malignant polyp. I think it would even be hard to inject through the malignant polyp because you're going through the tumor. But I think in the cases that Doug showed, the histology was assessed and that's why he proceeded with that injection in those cases. But I wouldn't, I wouldn't make that a practice for malignant polyps. Got you. But is there a risk of seeding doing just injection? I think, I think the risk has not produced itself clinically. Okay. Got you. And again, just as we're talking about distal attachments, how about snares now, going back to that question about, you know, favorite snares or things. And again, without, you know, getting into who manufactures, et cetera, but the types of snare, the shape of the snare, I mean, Joe, I mean, I see you nodding your head. I mean, do you sort of like do it based on the location of the polyp, how it sits when it's, you're in the five o'clock, six o'clock position, or do you just have one standard that your nurse automatically opens? We, and I think Tanya could probably speak to the more nuances of this, but, but basically I, I use a cold snare. I rarely do hot snare. Most of the polyps are going to be less than a centimeter. And so I use a regular cold snare. I think that one of the things we didn't talk too much about is, is snare stalling. And that one of the things that I've learned to do with more, with larger sub-centimeter polyps is to make sure I take a wide margin, but I'm not taking too much tissue. So I'm not having that problem of having to go through the, the, the, the, the, the tissue. And I, I know there have been some studies that show this benefits of certain cold snares or not. I used to use snares that could be hot, but since I rarely use heat for something certainly less than a centimeter or even less than 15 millimeters, I'm, I'm just doing a dedicated cold snare. So Tanya. I tend to have a 10 and a 20 as my go-to oval snares braided. The stiffness of those are great for EMR. I do use mainly cold for the one centimeter or small polyps. And I would say Doug showed and John today, well, that the snare size can be prohibitive. So don't always reflexively go to a larger snare. Sometimes you actually need to go to the smaller snare to capture the appropriate tissue. So that's just something to keep in mind. And there's certainly so many in the market, but I would say keep it simple in terms of your inventory that most of the time having a couple of them will do the job. Right. I mean, Tanya, that's a good point is like, if, unless you're planning on removing the polyp on block then it makes sense to go to a larger snare, right? So if you have a two centimeter polyp and you think you can remove it on block, use a two centimeter snare, right? I mean, that's the time to use it. But if you have a four centimeter, three centimeter polyp, there's really no need to go to a large snare size. Start with a 10, 15, whatever you feel comfortable because you know, you're going to do it piecemeal anyway, and you're not going to grab it. And the larger the snare becomes, it's becomes much more difficult to grab the tissue at the edges and to do it. Cesare, you mentioned ESD. So one of the questions on that last case again was, do we, or in general, the question one of the attendees is asking, do we really need ESD? What's the role of ESD now if we can just do piecemeal EMR, Cesare? Yeah. The role of ESD, for instance, in the proximal colon is mostly to reduce the risk of recurrence. Of course, in very expert hands, the risk of recurrence is only one out of 5%. But in real world, the recurrence is much higher than that. And there is the randomized trial by Jeremy Jacques that ESD reduces substantially the risk of recurrence. And it also allows a better histological analysis. So I feel that, I agree, clinically it is not so much relevant yet, but there is some evidence coming that ESD may be the future of resection also in the proximal colon, especially if technological advances such as traction or a second arm would come soon. I think, if I may add to all the great comments, is that in general, for large benign lesions in the colon, piecemeal EMR has been shown to be curative, right? Effective, safe. And then there's a very, very in the colon subset who we may need to do more on because of fibrosis or because of concern for a more advanced histology. And I think the literature is showing perhaps more of that in the rectal area, which may be good news because ESD may be more accessible in the rectum and safer. And so that's probably where it will go. But I think as of today, there's very few indications for ESD in the colon for the general clinical. It's more of the technical aspect, like fibrosed IBD patient, right? Like with concern of, I mean, there are indications, but those are few, particularly in the colon. And there's some questions about the type of solution and why do we use, you know, methylene blue. And I think if you're raising the lesion and part of your reason to raise the lesion is because you want to define the margins, using a blue dye really helps. So I just urge all our attendees that if you're doing that, try to have something with a coloring agent in it, because that really helps you, you know, do that. And then also a question about this evulsion technique. So let's go around the panel and see who uses hot versus cold evulsion in the situations when there's residual polyps. So Joe, I think I heard that you do hot, right? I mean, is that your thing? I do hot. I mean, I'm very, you know, certainly like people like Tanya and Heiko, I defer to them. That's why, you know, I sort of asked you. I defer, I have Heiko next door and he likes doing cold. And so I try to adopt that, but I really feel better with heat. I just feel like, you know, one of the things about the cold resection is that, you know, it doesn't give you the, you know, the resection that heat is going to do. So I prefer heat and I'm very careful about doing the proper techniques so we're not burning, certainly when you're in the middle of the scar there. So that's what I do. Okay, Cesare and Tanya. I do, I mean, honestly, probably for historical reason, we do it cold, also with the forceps biopsy. But then I agree that we take the tip of the snare and we heat it up. So at the end, the result is the same. I think it's the same. Agree. Sometimes for visibility, if I don't want the bleeding, I may do it hot. If I want to, like in a case where I'm concerned, it may be, like what Doug was just showing in that last case where he's like, is this fibrosis or is this actually lesion? In that case, I may do cold so I can submit it separately for the histology. Whereas the hot avulsion, it's such a small specimen that I wonder about the histologic assessment of it. Right. Yeah. The histology definitely, you know, makes it challenging if you're doing the hot there. But again, I think hopefully all the attendees also gather from this and the reason for this discussion is not to show that we don't agree on stuff, but it's just to show that there are different ways. Also, just as we talked about, you know, the types of clip, how do you want to do it and you keep it open, you don't. I mean, there are some areas where the guidelines that Joe, Tanya and Doug and Cesare have written are very clear, but then there are also areas in which it's based on your practice. But, you know, if you start doing something really well, I mean, I'd say just stick with it and whether it's cold or hot really doesn't matter. There was a question about decision tree to choose cold versus hot EMR. And I think we did answer that during the first couple of cases. I mean, specifically now the guidelines clearly state that, you know, polyps 10 millimeters or lower, I mean, you can remove with cold. I mean, there's really no discussion about that. And the size keeps on changing every day. So please follow the guidelines, but also cesile serrated lesions. I think now any size can be removed pretty much with cold piecemeal EMR. So, I mean, I think that's just something to keep in mind, you know, about that. And then the only other thing I'd say for that is whenever there's a new technique, there's technical success and then there's like oncologic outcomes or long-term. And so with all of these two, as Prateek's saying, continue to follow the literature because the generalizability of the techniques, the long-term outcomes of the techniques, the cost effectiveness, those are all things that come after we show first technical success. And I think to Tanya's point really quickly is like, when you look at cold resection, Daniel from Montreal had higher recurrence rates in his practices, which tend to be more private practitioners as opposed to a lot of these large studies in which experts are doing the resection. I feel that we can agree that if there is a bulky area, you cannot use cold. If it is flat, then it is a balance between benefit and risk. But if it is bulky, cold is not the way to go. How about the question about using epinephrine in your lifting solutions? Does anybody use that? Cesare is giving a thumbs up and the Europeans are always crazy. So I wouldn't trust his answer. So let's go to Tanya and Joe and see whether you guys use any epinephrine when you use injecting agents, lifting agents. I use a small amount in the rectum, mainly that's the only area. And I actually then alternate back to the one with my injection without it. So I do think it can be helpful to keep the clean field, decreasing that bleeding. It causes that blanching sometimes. But I use a little in specific, but not routinely. So Tanya, you're saying in the rectum, you use it, right? In the rectum, it's much more vascular. The lesions are larger. They're often bulkier, like Cesare is saying. And so I tend to use it there. Yeah, I also use it for penucolated, or penucolated we inject with the epinephrine. Yeah, we didn't talk too much about it, but if I'm going in for a colon, this is the polyp the size of Cleveland, I will inject as I go in and when I come back, it's significantly shrunk. I will say that you should expect people to have a little bit of discomfort afterwards. It's a little bit unnerving because it'll be localized discomfort. And you're saying, is this what's going on here? You have to be careful. And we don't think about this, in people with heart disease, you really should dilute it by tenfold. Because typically what I'll do is I'll get the, I don't know, Tanya and Cesare do, but I get the one out of the code card and then I will dilute it. It's not always easy to do, but people with heart disease, I do that. Okay, great point, Joe. Joe, I didn't know whether you liked Cleveland or not with that comment, but thank you for bringing that up. Now we're going to go to Doug and the IU team there. I think they're all ready for it. And again, a masterful job by the team as always. And I think hopefully everyone online agrees with that. So we'll have, donate over to Doug and his team for the final words. Doug. Hey, thank you so much Prateek. We just wanted to say, you know, goodbye to everybody. I want to thank my partner, John Guardiola, for helping us do the cases. Megan Kane, our director. We had several of our fellows here, Aziz Buran, Ben Burial, who's scoping next door. My partner, Umar Badi. So we had a whole team of people, all of our fellows and techs, and we so appreciate their help. Appreciate the panelists. You guys were fantastic. I couldn't have made four better selections than Prateek, Tanya, Joe, and Cesare. And thanks all of you for attending and appreciate it very much. Thanks so much to all the ASGE staff, everybody up in Chicago. This is really a joint IU-ASGE production. We appreciate you very much. All the best to everyone. Thanks Doug and team. Nice job guys. Bye. Thank you.

endoscopic procedures

endocuffs

polyp resection

endoscopic submucosal dissection

lifting solutions