For those of you that are back before we go on to the next talk, I want to address a few terminology questions that keep kind of appearing in the Q&A box. So when we say conventional adenomas, we are talking about a group of lesions that are always dysplastic. First of all, they always have dysplasia. It's either low-grade or high-grade. They also can be described as having either tubular components or villous components or a mixture, which we call tubulovillous, of course. So virtually every adenoma, conventional adenoma, can be described as having higher or low-grade dysplasia and having tubular or villous elements. But if you just get a report back of adenomatous polyp, then I think generally the assumption is that it's a tubular adenoma with low-grade dysplasia. The great majority of them are tubular adenomas with low-grade dysplasia. High-grade dysplasia is still a benign lesion, and you should treat it as a benign lesion. High-grade dysplasia has been shown in several studies to be a risk factor for recurrence. But again, if you've endoscopically resected a lesion with high-grade dysplasia, if it's fully resected, it's cured, and it's not going to come back later as cancer. When we talk about the morphology of adenomas, we've been using these terms granular and non-granular. I personally think that those terms are not useful in the description of serrated lesions. They just don't help. So usually when people are talking about a granular lateral spreading lesion, they're talking about an adenoma. A non-granular lateral spreading lesion is an adenoma, and a serrated lesion is a serrated lesion. Now, a traditional serrated adenoma is a rare lesion. Traditional TSAs, they're different than SSLs in many ways. First of all, they are dysplastic. They have a different form of dysplasia under the microscope. It looks a little bit different, as often more kind of eosinophils. They oftentimes in clinical practice get confused with tubular villus adenomas, because they have sort of frond-like features to them. TSAs, they have some features endoscopically that you can sort of predict, but you can be surprised, too. The endoscopic, sometimes you get a report of TSA and you didn't really anticipate it. You thought it was a conventional adenoma, but TSAs officially are classified in the serrated class, but endoscopically, they look a lot like adenomas, actually. So they could have sort of a granular appearance, but SSLs, when you're talking about SSLs, it's not helpful to talk about them as granular or non-granular. It doesn't even really make sense, and so forget about that. Now people have asked about SSL, SSA, and SSP, so we've had this, it's like a history to it. SSA is a term that was originally used to describe these serrated lesions that we now call SSLs. It was used to try to give them a sense of importance, because everybody said, oh, adenomas are important. We got this completely different set of lesions. Let's make them important, too. Let's call them SSL serrated adenomas, and it's a terrible, terrible term because they're not dysplastic. Adenoma, we have come to understand conventional adenomas as dysplastic lesions, SSAs, SSPs, SSLs. Again, those terms are all, they're all synonymous. SSA went from SSP because people said, we've got to stop calling them adenomas, and they call them SSPs, and then people said, you know what, it's really not so great to call them SSPs because most of them are flat. They're not polyploid, so maybe we just ought to call them SSLs, SSL serrated lesions, and I think that that is the best term because some of them are polyploid, but most of them are, you know, would fit into the flat category. They're Paris IIa, but granular and non-granular, that doesn't help in the serrated group of lesions. So SSLs are, for the most part, non-dysplastic, but as we've talked about, they can have a focus of dysplasia. SSA, that's a bullcrap past history term. It belongs in the past. Just because it's called SSA doesn't mean it's dysplastic, all right? SSAs, most of them were not, SSA and SSL are the same thing. Just terminology, the lesions haven't changed, just the terminology changes, but we've had a lot of repetition in the course, and I think it's been great. I really have, I've liked it because I think these concepts that have come out about resection and discussing them multiple times have been very helpful in the whole process of addressing this terminology and trying to get at how we use morphology and how we use, you know, PIP patterns in order to say what kind of a lesion this is and what sort of chance it has to have cancer. I don't think you can discuss it enough because they're some of the harder concepts to understand about colonoscopy. Any other things that we should talk about? We've talked about cancer in the colon is submucosal invasion. Superficial submucosal invasion officially means less than 1,000 microns, one millimeter. Deep submucosal invasion means more than a millimeter or 1,000 microns. You know, there is nothing that's really sensitive for deep submucosal invasion. Deep submucosal invasion traditionally was one of those unfavorable features that made us tend to send the patient to surgery because of an increased risk of lymph node mets. But now we have this data that shows that deep submucosal invasion, if that's the only feature that there is, the risk of lymph node mets seems to still be low. So I think concepts are changing about that. Endoscopically, there is nothing that's sensitive for deep submucosal invasion. But if you have nice three changes, this disrupted vascular change, that's very specific. I mean, it is basically that patient's always going to have deep submucosal invasion. And traditionally, when we would see that, we would pretty much always biopsy that area, get the biopsy forceps right in that area, document the cancer, send the patient to surgery. And, you know, if the morphology is of a big cancer, like one of those ones I showed in the video quiz, that's still the right way to go. A very small lesion with deep submucosal invasion, you know, you could make an argument at times, especially, you know, I mean, especially in a poor surgical candidate, to remove that. I would, if it's very small, I would tend to remove it by full thickness resection. Or if it's bigger and the focus of deep submucosal invasion is very small, remove the rest of it by some other method. And then if you can remove the small part by FTRD, I don't know that ESD, you know, helps that much in a lesion that's got deep submucosal invasion. In the rectum now, there are endoscopists who are doing endoscopic intermuscular dissection. They dissect between the circular and the longitudinal muscle. And you can do some things in the rectum that you can't necessarily do elsewhere. But I would say that superficial and deep submucosal invasion are concepts that you want to understand. Any other terminology concepts that you guys have thought were confusing from some of the questions that we've seen? No. OK. I think these are the main ones. OK. So I'm going to go over to the last talk here, which is on kind of trying to put this all together and to think about it from the perspective of, you know, approaching this in clinical practice. And I think, you know, I'll try to not cover things that we've already covered in detail. But I want to touch on a few concepts and try to think about where you're going to position kind of your own practice with regard to the clinical practice. And with regard to, you know, complex resections. And so let me see if I can do that real quickly. So taking on larger polyps in practice, pre-referral management. So Amit really nicely summarized that. We've got too many benign polyps going for surgical resection. So if you think about where our public health problems are with regard to resection, I would personally say that we have a lot more trouble with polyps that are benign and that are endoscopically resectable being sent for surgery than we do the occasional cancer that gets resected piecemeal and has only superficial submucosal invasion and goes to surgery because it was piecemealed. I think that's probably fewer patients getting unnecessary surgery than compared to this whole issue of benign polyps getting sent for surgery. And, you know, there are a variety of obstacles to this. So one of the obstacles is reimbursement is not very good. So, you know, it's true. It's, I think it's, it doesn't make sense, but it's true that you make the most money in colonoscopy by doing screening and surveillance and diagnostic colonoscopy. We talked about these complication ramifications. I think there, some of the issue is probably resistance to travel. I, you know, it's hilarious in a tertiary center. I will have people flying an airplane halfway across the country to have an endoscopic resection. And I have people in Indiana that won't drive from the next county because they're too intimidated by the traffic in Indianapolis. So there is resistance. I think there's resistance of small hospitals to losing patients. Sometimes there's an unwillingness to admit limitations to patients and colleagues. I will say now that I've seen two malpractice suits against gastroenterologists because they sent a patient with a benign polyp to surgery and the patient developed a leak. And then it became clear that they probably didn't need the surgery to begin with. And both the GI doctor and the surgeon were sued. So I don't know how much of that there is going to be, but I do think there's medical legal risk. I think that patients for the most part really appreciate when you honestly tell them what your limitations are. I've got lots of limitations with regard to all sorts of things, even in GI, pancreatobiliary disease. You know, I need help from my advanced endoscopist, my motility experts, you know, whomever. So I think it's, I think patients appreciate for the most part when we admit our limitations. So when you're in a tertiary center, one of the issues that comes up is, you know, what are the deficiencies that you see in the way polyps are managed before they are sent to you? And I will say that the bigger the catchment area, I think the harder it is to do this. We had an advanced endoscopist who did a great job up in Fort Wayne, Indiana, and he had a smaller group of physicians and he really got them on a very well understood sort of threshold for what they should refer. I will say I have a hard time doing that because I get referrals from just such a wide variety of sources. But these are some of the messages I think that go out. So tattooing, unnecessary tattoos. So we generally, we don't need to tattoo in the cecum or the rectum. I don't think you need to tattoo anything that is, if the ileocecal valve is in view, when you see the lesion, just take a photograph of the lesion with the valve in view, and that is plenty to document the lesion. When you tattoo, you want to really back away. One thing that people underestimate is the concentration of carbon that's in spot. Spot is the most commonly used agent now. And spot EX has more carbon in it. And if you put a one centimeter tattoo in, it'll spread out sometimes over five, six, it seems like a huge area that it spreads out. And I see people sometimes using more than that. If you put it in the submucosa, a half an ML to 0.75 MLs is plenty to give a nice tattoo, and then keep it several centimeters away from the lesion, or put it on the opposite wall and then designate where you put the tattoo. I think insufficient assessment of lesions is an issue and inadequate photography. So we rely in my center a lot on photography. We have a triage system for all the referrals. And I look at pictures of all of them. We have a coordinator who gets a hold of these pictures. And a lot of the photography is quite good, but occasionally the photography is just not very representative of the lesion. And I will tell you that in Japan, when they do ESD, they scope the patient beforehand. The referral center scopes the patient. The patient travels to the referral center. They scope them just to look at the lesion and make a plan. But that doesn't work very well in the United States. And so we really need good photography. I think multiple photographs of the lesion from different vantage points can be very helpful. It's especially helpful, I think, for ESD because you need to block a certain amount of time. And you can take a picture of a lesion and make it look much smaller than it actually is. So representative photographs are very helpful for triaging. Tattooing. I talked about this in the medical legal risk and wrong site surgery. And we've discussed the need to approach it tangentially, lift the needle. You can make a subcube bleb with something else and then put it in there. Now, I do that occasionally, but I would admit most of the time I just don't want to take the time to do it. I will say that somebody asked about tattooing when you've already done an EMR. And I generally, if I can't see the ileocecal valve and I'm not in the rectum, I will put a tattoo, sometimes even in the rectum, I'll put a tattoo right next to it because I'm not worried about scarring or fibrosis from the tattoo at that point because you've just removed the lesion. You've created a lot more fibrosis from the resection than the tattoo is going to do. It's really before the resection that you wanna be careful about keeping the tattoo out from under the lesion. For cancers, I think the best thing is to just tattoo them on one side and not tattoo both sides. And I think the best place is the distal side because there are gonna be times when you can't tattoo the proximal side because you've got an obstructing lesion. So you kind of wanna develop a system within your institution for how you're going to tattoo. So the surgeons kind of have an expectation and then document very clearly. But I think the best place is the distal side, usually three to four quadrants. We talked about that with regard to medical legal risks. So when you're doing the injection method, here we've obviously just done the resection and we've tattooed it. The trick is to don't inject until you're pretty confident that you're in the right space. So you can see we're backing off with the needle. And then I just kind of flipped it up toward the lumen to see the bevel, and then just put a little bit in and then put the tattoo in. And with the current tattoos, an ML is plenty. So the bleb method, here there's a resection on the other side of that fold right there. So here you can see the bevel, or you can see the shape of the needle in the submucosa. You lift it up and then put a little bit of fluid. Here we're putting some saline in, and then that gives you a bleb that's easy to enter. I just usually don't take the time for that. Just use the same method, but put the tattoo directly in. I think I'll skip this, just more of the same. So areas of weakness, Amit mentioned biopsy. So never snare biopsy, never go into a resection without the intent to complete it. I tell referring doctors that I think that if they have done a resection and they come back and there's a significant recurrence, I would say don't mess with big lesions more than once or twice. I sometimes get referrals where the referring doctor has worked on it, the record was nine times, and then referred the patient. So these lesions will be heavily scarred over a significant area. And it becomes a very difficult process using these methods that Amit described of having to pick stuff up. This not biopsying is especially true for SSLs. Just if you've got a flat SSL and you don't want to take it out. Now, I hope we've convinced you that you can take SSLs out and do it with confidence using cold resection. But if you want to refer an SSL, don't biopsy it. Just don't biopsy it, period. Because if they're very flat, you will tack down the place where the biopsy is. I see people thinking that biopsying the edge is going to be safe, but the edge you're always going to get into the submucosa and there. And every time you create submucosal fibrosis, you make it more likely that some of these special techniques like the CAP method or evulsion are going to be necessary. Clip closure of cold resection defects. In general, I hope we've discouraged that. Not finding synchronous lesions. So I will tell you that when we're referred large non-penunculated adenomas or large penunculated adenomas, the additional number of adenomas that we find is four. 40% of the time, we find a second or more advanced lesion. 20% of the time, we find a second lesion that is 20 millimeters or more in size. And a little bit less than 1% of the time, we find another lesion in the colon that has cancer in it. And so it's important to realize that when you see a large lesion and you make a decision to refer the patient or delay the resection, that there's a very high prevalence of synchronous disease in these patients. And you've got to do a careful examination of the whole colon. And then I've also talked about counting serrated lesions. Now, what's the value of diagnosing serrated polyposis syndrome? Well, I think one of the values is that you immediately put the patient in a category where there's an accepted approach of short interval follow-up. And short interval follow-up, one of the things is it gives you another chance to clear the colon. So, usually with SPS, we will bring the patient back at least the first time in a year. If they have a very heavy polyp burden, we might bring them back every three to six months a couple of times till we've got control of the polyp burden. And you'll see some of these patients who have 10, 15, 20 large serrated lesions and 50 to 100 small ones. And people have asked like, how much can you do in one session? Well, as much as you can, but again, our reimbursement system is not designed to reward us for taking out lots of polyps. So, we do that because that's just part of the process of taking care of the patients. But everybody's got their limits. I've got my limits. And it comes down to just fundamental basics, right? If I'm an hour behind in the middle of the afternoon, I'm probably gonna take out fewer before I give up than I am the first case in the morning. So, we're all human and make decisions like this. So, I think one way to think about how you're gonna take these tools that you've heard about is to try to figure out what you think is your risk threshold and your efficiency threshold. I think these are both things that are important to people in practice is limiting complications and also this inefficiency thing, the fact that the most efficient and highest income approach to colonoscopy is to stay focused on basic procedures. It's a weird situation. So, very low risk and I think good efficiency is cold resection and hot resection of penunculated polyps. I would think everybody should feel comfortable with that in their practice. Intermediate risk and range of efficiency, underwater EMR. People have asked, can you do underwater EMR cold? Well, you can, but it was kind of designed as a method for electrocautery because when you're underwater, if you're piecemealing, you get bleeding into the blood and it gets a bit hard to see. So, there's no problem with removing, taking out an unblock underwater EMR cold, but for the most part, it's kind of an electrocautery technique. I think conventional EMR with electrocautery is sort of intermediate risk. People often quote the risk of conventional EMR perforation of about being 1%. I think it's, in my experience, it's lower than that. And when we do have perforations, we close them. So, I don't think conventional EMR or underwater EMR are real risky and they're reasonably efficient. Now, FTRD, the risk is a little bit higher because it's 2% in the literature. And it's relatively inefficient primarily because you got to go up, look at the lesion, mark it, come back out and put the other device in. In reality, it all depends on where it is in the colon and what the anatomy of the colon is. It's really a pretty quick technique. And I think it's rather quick to learn. You know, the learning curve is quite short. And then the highest risk, if you know you believe the perforation rate is about 5% with ESD, that's got the highest risk and also the lowest efficiency. So, if you're going to do ESD, I think it's probably a good idea from an efficiency standpoint to try to develop systems with the local insurers where you're getting paid a fair rate because we don't have a code for ESD. Or if you're like me, I'm an employee in a big healthcare system. So, I get paid by RVUs. So, I've seen people negotiate how many RVUs they're going to get to perform an ESD. And I will tell you, I mean, good luck with that because I've not been effective with it. I've tried to get my healthcare system to, if I do, for example, three or more EMRs in a single session to give me more RVUs, or if I take out more than 30 polyps, will you give me more RVUs? And they just say, no. So, but some people, you can be successful, especially if the healthcare system wants to have ESD, then say, I'm going to do ESD, but you're going to give me X number of RVUs to do that. So, by efficiency, I mean, some combination of the time it takes and the reimbursement that you get for it, or you're not going to be incentivized to do it. We've talked about this. I think everybody should be able to take out pedunculated polyps, these cold resection issues we've really talked about. So, I don't need to cover that, but I would say that that, we've sort of talked about the relative efficiency of this. Underwater EMR is extremely efficient. And if you mark the lesion, you can take the tip of the snare and mark the perimeter of the lesion, then that fulfills the demarcation requirement for EMR. So, I perform underwater EMR and I bill for EMR using the thermal demarcation method of billing for it. And it's very efficient. FTRD, again, a little bit higher risk. And we've talked about some of this. So, these are some of the ways that you can improve efficiency or the cost that the amount of reimbursement that you get for your time. And so, I think some of the people that we see doing a lot of ESD on the coasts of the country, these are people who have very, they have very successfully negotiated with their insurers or at least their main insurers to get what would be appropriate reimbursement for a complex procedure. So, I think this is a way to sort of think about this. And I think you have to take into account your own threshold for risk and complications, the community that you're in, how big your group is, how you want, where you're gonna position yourself in your group. And if you're gonna have a special interest in colonoscopy in my own center, my advanced endoscopists are not really involved very much in advanced resection. They do rectal ESD when I ask them to, because I think it's a lesion that is best treated by that. But they spend most of their time with ESD in the esophagus actually in modern practice. And other than that, they're doing EUS and ERCP and semicostal endoscopy like POM and G-POM. And so, it falls into my domain and I'm not an advanced endoscopist and I feel fortunate to have such a large role in endoscopic resection. But all these factors can come into play. I still like to do lots of routine endoscopy because I'm RVU based. And the more routine, I get paid better on days that I'm doing routine endoscopy than on days that I'm doing lots of endoscopic mucosal resection. I think we all have to decide for ourselves where to sort of fit in all of this. But I hope the information that you've been given today at whatever level you wanna be will help to make you a more effective and a safer colonoscopy. But most importantly, in the whole context of this, if there are things that are above your threshold, don't send the benign lesions to surgery. If the lesion is outside your risk or efficiency threshold, there's gonna be somebody who's willing to perform endoscopic resection. So the whole idea of that talk was really just trying to give a bit of an overview of some of the real considerations, I think that come into play in deciding how you're going to practice. So with that in mind, let's go to our wrap up session on colonoscopy and see if people have any additional. So coding underwater EMR is a question. So if you actually look at the EMR code, it says that there's a demarcation requirement, which I think you can fulfill when you're doing conventional EMR by the injection process, the delineation of the margin. I think, yeah, the way I approach it is I just make a faithful effort to fulfill the demarcation requirements. So for underwater, just to say, some people when they're doing underwater EMR will mark the margin like with APC or something, but just to save on another device, I typically will do some level of demarcation. It may not be like I'm really using it. I will admit, I try to do it to fulfill the code, but with the tip of the snare, with again, soft coagulation current, whenever you're using the tip of the snare, you want to have soft coagulation current. So I don't know if other people. You don't think the submucosal injection is a component of that, Doug? I'm always confused about this coding business. Do we get credit for CPT code 45390, which is the EMR code if you do underwater? Yeah, I think what Doug's saying is the demarcation part. The billers have reached out to me, or the coders at UCSF, if I forget to say, for example, using inject and cut EMR, if I forget to say that I demarcated the margins using NBI. So that's a way that at least they claim that if I say I've demarcated it using imaging, that you may not necessarily need to use cautery is why I'm bringing that up, Doug, is that if we document it using imaging, we've demarcated it in some way. They may just be looking for that term. I don't know. Yeah, so I mean, I think, Amit, I don't know that it's settled exactly how you do it, but technically for the EMR code, you're supposed to use some kind of demarcation method. So I think what Tanya is saying, very interesting, because we all hear different things from our individual coders, actually in probation, when you use the EMR code, it will ask you specifically how you demarcated the lesion. And you can designate from a group of options about how you did it. But I do think that you can use the EMR code if you use demarcation. I certainly would not abuse that. And so I would only do it. Like I say, if I take out something that's less than 20 millimeters underwater, I'm not going to submit that with an EMR code. But if it's a large lesion that I use the snare tip to demarcate, then I think it's fair to do that. I mean, that's my own solution to it. I'm not saying that's absolutely the right answer or that I'm a coding expert, but there is technically a demarcation requirement with EMR, as I think Tanya was saying. Okay, looking down at the list here, as someone, I'm going to turn this into, some of these things are like copies of the questions stuff and I'm going to have to turn that over to some of the ASG staff to see if they've got anything. I appreciate the encouragement there. I'm not seeing too much else. So I'm asked at the top question. Oh, Amit has answered this question. Yeah, so I think it's in the 10 to 20 millimeter size range for non-pedunculated lesions, there may be times to inject but it's not always necessary to inject. And so some individual decision-making goes in. I think it's kind of funny that if you look across the literature, we have less controlled data and even observational data about 10 to 20 millimeter lesions than any other size group. We've got a huge amount of data about the non-pedunculated lesions that are 20 millimeters and larger and a huge amount about small lesions. And I think we're going to see more and more, but it's part of the reason why a variety of different approaches are pretty acceptable in that size range.

colon polyps

adenomas

dysplasia

serrated lesions

endoscopic resection

polyp classification

synchronous lesions