It's my pleasure to introduce our second speaker today, which is Dr. Amandeep Shergill. Dr. Shergill is a professor of medicine in the Division of Gastroenterology at UCSF. She is the director of endoscopy in the San Francisco VA Medical Center. She is an expert in ergonomics and co-founded the UCSF UCB Center for Ergonomic Endoscopy. And we're delighted to have her speak to us today about refocusing on ergonomics during endoscopy. I'd like to thank the course directors for inviting me to speak today on refocusing on ergonomics during endoscopy. Here are my relevant disclosures. Over the next 20 minutes, what I'd like to do is review with you these top truths and tips when it comes to ergonomics for your endoscopy practice. The first truth is that if you have an endoscopy related injury, it's really important to know that you are not alone. Multiple survey-based studies have established a high prevalence of injury in endoscopists, with the most recent study of almost 1,700 ACG endoscopists demonstrating that 75 percent of respondents experienced injury related to the performance of endoscopy. And this brings us to the second truth, which is that performing endoscopy is unfortunately a risky business. And this is where ergonomics comes in. First off, what is ergonomics? Ergonomics is the study of how work affects people physically and cognitively. It quantifies human capabilities and limitations and then it applies it to work. So it's the science of fitting a job to the worker instead of forcing a worker to fit into a job. In order to fit a job to a worker, ergonomics relies on many different subspecialties, including anthropometrics, which is the study of human dimensions, and biomechanics, which is the study of how we produce force and generate movement. The idea is that in order to optimize biomechanics, in order for us to be able to attain neutral postures while utilizing a tool or in a work site, we really need to take into account the workers, the different sizes and breadth of workers, including their strength in order to design tools and tasks that are within safe limits. In the ergonomics literature, there is evidence for a causal relationship between physical work factors, such as non-neutral posture, high force and repetition, and the development of work-related musculoskeletal disorders. Specifically, posture has been implicated in the development of neck, shoulder, and back pain, and the combination of posture, repetition, and force has been implicated in the development of distal upper extremity disorders, such as wrist tendinitis and carpal tunnel syndrome. So what happens with work-related musculoskeletal disorders is that there is a load, physical stress acting on the body, and that extra load can be how we hold and manipulate the control section or the insertion tube, or how we're interacting with our work environment. And depending upon how frequently we're doing it, for what length of time we're doing it, and what force is required for us to use that tool or work in that work site, over time, these external loads overcome our internal loads and tissue tolerances of the muscles, tendons, ligaments, and joints, and these repeated exposures eventually lead to pain and then ultimately can lead to disability. Our group sought to establish the presence of these biomechanical risk factors during the performance of colonoscopy by capturing forearm muscle load and thumb pinch force during routine colonoscopy. And just as a high-level overview, what we did is we compared these forearm muscle loads and thumb pinch forces to establish risk thresholds to determine if performance of colonoscopy was high-risk, moderate-risk, or a low-risk procedure. What we found for the left forearm muscle loads is that they exceed the highest risk thresholds during all phases of colonoscopy, indicating that this is a very high-risk exposure that's happening. The right forearm muscle loads exceed the moderate-risk threshold during all phases of colonoscopy, with female endoscopists experiencing some high-risk exposures, especially during insertion. We looked at thumb pinch force, specifically percent time spent in forceful pinch, which in prospective studies has been associated with the development of Kerpel Tunnel Syndrome. Again, we exceeded this high-risk threshold during all phases of colonoscopy, especially for female endoscopists. So it becomes important for us to consider how we can reduce this high risk of injury, given the high prevalence of injury as well as the presence of these biomechanical risk factors indicating high-risk exposures. And I often have endoscopists approaching me about what they can do in order to reduce their risks, and it's critical for us to understand that in the hierarchy of controls, the endoscopist is at the bottom of an upside-down pyramid. What do I mean by that? Well, when we think about how we can apply ergonomic principles to GI endoscopy to improve the fit of performing endoscopy to the endoscopist, in the hierarchy of controls, the most effective mitigation measures are going to be eliminating or substituting the risk altogether. And that's really going to require prevention through design, involvement of the endoscope and device companies. And so the next most effective control measure is going to be engineering controls. That's going to be a physical change to either our tool or our workplace to improve the fit between the endoscope and the endoscopy suite to the endoscopist. The next most effective control is going to be administrative controls, which change the way we work, such as ergonomics, training and safety cultures, implementing timeouts, as well as proactively maintaining our endoscopes. And then the least effective control measures, what's at the bottom of this pyramid, is personal protective equipment, what the endoscopist might do themselves for themselves in order to mitigate their risk. So the key is that we need to think about how we can design our tools as well as the endoscopy suite to really fit that breadth of workers, that fifth percentile female to that 95th percentile male, so that everyone can attain neutral postures and work in their position of greatest strength and within safe exposure limits. So are there engineering controls that we can consider that may improve that operator tool interaction? Right, left dial adapters are available that can be placed on that right left dial in theory, increasing the reach of the thumb to the dial and making it easier to access it for scoping. This was studied in one small abstract based study where retroflection was rated easier with the dial adapter in place. Otherwise, no significant difference was found with or without the dial adapter. Although anecdotally, folks who use this do find benefit from it. Our group was able to show that the use of an anti-gravity support arm was able to reduce the static load of the control section on those left forearm muscles, specifically the left extensio carpi radialis muscle, as shown in the simulated study. So anything that might reduce that static load, such as a support stand, may be a benefit. Anything that decreases exposure time can overall decrease our risk and so can be an important mitigation measure. And now caps have been shown to decrease time to sequel intubation and the specific kind of cap has been shown to not only decrease withdrawal time, but actually increase ADR. So this may be an important ancillary tool to use that may decrease exposure time overall. Where we have the most control is over our work environment. So important engineering controls to consider are measures that will allow us to increase the adjustability of the work environment to accommodate that 5th percentile female to that 95th percentile male. The most important determinant of overall posture is that monitor, where it's positioned and at what height. The monitor should be placed directly in front of the endoscopist, just below eye level. So the resting eye angle is about 15 to 25 degrees below the horizon. And in order to accommodate that 5th percentile female to that 95th percentile male, that monitor needs to be adjustable either on an adjustable arm that's wall mounted or on a boom in order to accommodate that resting eye angle. If that monitor is too high, that's going to result in neck extension, which can overall, because of the non-neutral posture for an extended period of time, be a large contributor to neck pain. Bed height is another big determinant of overall posture. And in order to have a neutral trunk, shoulder, and elbow posture, the bed should just be at or below elbow height. And it should be adjustable to accommodate that 5th percentile female to that 95th percentile male. A common question I get is whether or not there's an optimal way to hold and manipulate the endoscope. I think we have a lot of work to do in order to understand how best to hold and manipulate the scope. But this is an example of what's taught in England from the National Bowel Cancer Screening Program, where the scope is held horizontally and the larger muscle groups of the upper extremity are used in order to result in tip deflection. So instead of holding and pinching the insertion tube, what happens is that that scope is moved around using the larger muscles of the biceps and potentially even the trunk in order to result in that tip deflection. This can transfer the loads from the smaller muscle groups of the hands to the larger muscle groups of the body and is something to consider implementing. When holding the scope horizontally, it's also thought that when that umbilical cord is behind the scope, that that leads the scope to be perfectly balanced such that it can be balanced only on one finger and in theory will allow for better access to the dials as well. In contrast, others believe that by having the umbilical cord draped in front of the wrist, that that allows the endoscopist to use the all fingers technique where the fingers and the thumb can be used to support dial manipulation. While there is an ongoing debate about how best to hold the control section, there is no debate that the power grip is a more powerful way to hold the insertion tube than the pinch grip. So the pinch grip is when the fingers are flexed towards the tip of the thumb, and it's estimated that a pinch grip can be three to five times more stressful on the tendons than a power grip, where the fingers are flexed towards the palm and is 75% stronger than the pinch grip. If you're finding that you're having to apply a lot of torque to that insertion tube, consider ways to convert a pinch grip to a power grip using gauze or towels. Another important consideration is scheduled endoscope maintenance. We know that exposure to biomechanical risk factors are high even when the scopes are performing at the manufacturer-recommended specifications, and that over time, the angulation control wires can stretch. This leads to decreased responsiveness of the control section, such that more work may be required to achieve a comparable or even lesser degree of tip deflection. And angulation repairs are one of the most common types of endoscope repairs. In this study, evaluating actual endoscopic tip angulation to the manufacturer-prescribed angulation, only two of 20 colonoscopes reached the maximal angulation that was recommended by the manufacturer, and eight of 20 had recently undergone their yearly maintenance check just one month before this measurement. It's really important, then, that our scopes are working as we expect them to. Only one endoscope company has a proactive endoscopic maintenance program, where you send your scopes in for evaluation after a certain number of scopes. The others have a reactive endoscope maintenance program. I would recommend, in that case, to consider having a bedside evaluation, where they can come and just do a rough estimate of the angulation, and if it's off by more than a certain number of degrees, it can be sent in for more formal evaluation. And so, in the operating theater, it's important for you to know that you, the endoscopist, are the star. I'd like to empower you all to take those first few seconds of the procedure for yourself. Position that monitor optimally, so that it's right in front of you, so that your resting eye angle falls in the middle of the screen. Position that bed so that you have a neutral shoulder, back, and elbow posture. Be absolutely the most comfortable you can at the outset of that procedure, because while your nursing staff, your anesthesiologists may be able to take a break, you're going to be in there for the entirety of the case, so it's critical that you start out the procedure as comfortable as possible. This study evaluated the impact of a physical therapist on a formal evaluation of work. The physical therapist evaluated static and dynamic postures, made recommendations for procedure suite optimization, as well as developed personalized wellness exercises and pain education. And in the subset of endoscopists that were experiencing pain, this was demonstrated to be a significant benefit. And that brings us to the next tip, which is don't underestimate pain. And that brings us to the next tip, which is don't underestimate the value of a break. While there have been numerous studies that have evaluated optimal schedule as it relates to patient-related outcomes, such as ADR, there have been no studies that evaluate optimal schedule as it relates to physician-related outcomes. The best advice that we can give is that you should be fully recovered from a prior day's endoscopy session before starting a new one, so that if you notice that you are having any kind of aches or pains, to make sure that you're building in at least half days or full days of rest between endoscopy sessions. During the endoscopy day, it's also important to consider how we can convert static loads to dynamic loads, so that we can optimize the amount of blood needed to a muscle and the blood flowing to that muscle. When we are in a static load, for instance, prolonged standing or holding that scope for a prolonged period of time, the muscles are contracting, so there's a lot of blood that's needed, but because the muscles are contracted, blood can't flow to that area. Anything that we can do to convert a static load to a more dynamic load, where the blood needed and the blood flowing are better matched, can decrease pain. Floor mats and shoe inserts can help to convert static to dynamic loads. They've been demonstrated to reduce discomfort and fatigue after several hours of prolonged standing. Shoe inserts are about as comfortable as the most comfortable floor mats, and the greatest benefit is after several hours of standing. There was an interesting study looking at unstable shoes. It's the shoe stone here, where you can easily see how that can lead to rocking while you're standing. In this study, lower leg discomfort rating was reduced significantly while standing on unstable shoes, and the lower leg volume change was lesser, meaning less edema for unstable shoes during standing. Anything that's going to convert those static to dynamic postures can be a benefit. The best shoes are the ones that are most comfortable for you. General considerations are to have a wide toe box, which accommodates feet as they naturally expand throughout the day. You want your shoes to be durable, lightweight, and slip resistant. Consider at least having two pairs of support sneakers or clogs at work, because a shoe's cushioning becomes completely compressed after six hours or so and no longer offers support. So if you have a long shift, consider switching shoes halfway through a long shift in order to get some cushioning back and some support back from your shoes. Use of compression stockings results in reduction of subjective complaints of leg fatigue, pain, and swelling, especially at work requiring prolonged standing. In studies, there have been objective reduction of leg swelling and leg fluid volume with the use of compression stockings, and the benefits are most pronounced in workers with baseline chronic meanness insufficiency. In order to achieve benefit, calf-length compression stockings can be used, and they should exert pressure above 10 millimeters of mercury to improve subjective symptoms. Again, think about how you can convert your static postures during a procedure into more dynamic postures. So that's consider alternate positioning, sitting versus standing. So there's increasing antidotes about sitting endoscopy. The main caveat to this appears to be make sure you have your monitor correctly positioned and can be lowered enough so that you're not increasing neck pain related to sitting endoscopy. Consider a larger role of assistance. Whenever you can take a break, rest your hand on the bed or on the patient and try and shake out that hand that's been holding that control section to minimize those static loads. And again, consider implementing those micro-breaks by resting the scope, shaking out the hands, as well as implementing some stretching exercises post-procedure. In the study of ACG endoscopists, there was a lower likelihood of endoscopy-related injury in those who took breaks and micro-breaks, and the duration of breaks was not significantly associated with endoscopy-related injury. The moral of the story is, at some point, give yourself a break, even if it's a small one. I had the pleasure of working with Dr. Raju and now Kusasaki on a series of post-procedure stretching exercises that can be found through the ACG video library that basically goes through, as you're degloving and degounding at the end of a procedure, different ways to reactivate your core and stretch out the muscles that were used. An important signal is pain, so it's critical that we also respect pain if we are experiencing it. Cumulative injury, as we discussed from overuse, is going to first lead to pain before it leads to degeneration, tendon weakening, and ultimately that potential for failure. And if you're having pain, think about what might be contributing to it. So if it's distal upper extremity, think about the biomechanics of scope handling. If it's more neck, shoulder, or back, think about your posture, that monitor position and height, and that bed height. And if it's more back, lower extremities, think about how static loads might be contributing. So it's important that we recognize these symptoms. In the early stage, the symptoms may be aching and tiredness of the affected limb that occurred during the work shift but disappear at night and during days off work. And there may be no associated reduction of work performance. But in the intermediate stage, aching and tiredness occur earlier in the work shift, persist at night, and there can be a reduced capacity for repetitive work. And in the late stage, aching, fatigue, and weakness persist even at rest, and there may be an inability to sleep and to perform light duties. In this study of European endoscopists, 20% of endoscopists experiencing pain were in the early stage of injury, 45% were in the intermediate stage, and 22% had already progressed to the late stage where they were experiencing pain all the time, including at rest. In the absence of better guidance in order to properly respect pain, think about this two-hour pain rule, which is advocated by the Arthritis Foundation, and it uses a guideline to evaluate excessive activity. If you have pain for two hours after the activity, in our case after endoscopy, it means we've done too much and we need to figure out a way to reduce that pain and reduce that risk of injury. If we have experienced pain or injury, the road to recovery will include modifying activity. What are we doing and what do we need to do to get better? How can we reduce stress or biomechanically deload that joint or muscle group? This will likely involve physical therapy with stretching and strengthening, as well as some degree of pain control, which should be done in conjunction with other physicians. The last tip is that getting older isn't for the weak. As Dr. Stone said, train your body for the sport of aging and play on. I think many of us have heard the term endoathlete. I tend not to embrace that term because I think it puts too much pressure on endoscopists to bulk up in order to be able to perform endoscopy. However, it's well known that gender is the most important predictor of strength, and women at their strongest in their 20s are equally as strong as men between 70 to 80 years of age, and over time, both men and women lose strength. The aging process leads to a distinct muscle mass and strength loss. Muscle starts to deteriorate when we reach our 30s, and after age 40, we lose an average of 8% of our muscle mass every decade, which accelerates at an even faster rate after age 60. And both resistance and aerobic exercise can be very useful to counteract sarcopenia and the associated metabolic alterations of the muscle. In the ideal world, where we all have lots of time and lots of money, we all have personal trainers that can help guide us through this journey. But we don't necessarily need that. One study demonstrated that you can build strength in just 13 minutes with a single brief set of each exercise if you work really, really hard. The New York Times series, Year of Better Living, has a series of articles that talk about how we can invest in our health. So if you, like me, lack the time or resources to be able to hire your own personal trainer, this has a great series of exercises that you can do from home to help build back and maintain some of our strength, which is really so critical as we get older. And so in summary, as we're thinking about how to refocus on ergonomics for endoscopy practice, it's important to know that if you have an endoscopy-related injury, you're not alone, that performing endoscopy is unfortunately a risky business, and that in the hierarchy of controls, anything you do by yourself is going to be at the bottom of an upside-down pyramid. So think about how we can leverage other mitigation measures that are going to be more effective. In the operating theater, you, the endoscopist, are the star. So really take those few seconds for yourself at the beginning of a procedure. Don't underestimate the value of a break. Respect pain. And because getting older isn't for the weak, invest in yourself as well. Thank you for your time and attention. Well, that was some great advice. So now we're going to move on to our next presenter, Dr. Brewer. Dr. Brewer is the Director of Endoscopy for Johns Hopkins Hospital in the National Capital Region. She is an expert therapeutic endoscopist who's completed not only an advanced endoscopy fellowship but also motility fellowship. Dr. Brewer has published extensively in advanced endoscopy, and we are delighted to have her joining us today and look forward to hearing about the evidence-based approaches to periprocedural anticoagulation. Dr. Brewer, thank you. I want to thank everybody. I want to thank especially ASGE, Dr. Lennon, and Dr. Elmunzer for the opportunity to discuss about the management of anticoagulation in endoscopy. I have nothing to disclose. In the next 20 minutes, my goal is for you to learn what are the conditions of high risk for thromboembolic events. I also want you to learn what procedures carries high risk of bleeding. I want you to learn when to stop anticoagulation and when to resume them after endoscopy. So it's 7 a.m. Monday morning. You're about to start your endoscopy list, and you're reviewing your cases. You have a 65-year-old man with past medical history of mitral prosthetic valve metal. The patient is on Warfarin. There is no family history of colon cancer. Patient is asymptomatic from the GI standpoint, but he has a positive multi-target stool DNA test or ColoGuard, and the patient is here for a screening colonoscopy. How do we manage this? How do we approach this case? Before doing endoscopy in patients on anticoagulation or antiplatelet therapy, we need to ask ourselves five key questions. One, what conditions have increased risk of thromboembolic events when stopping the antithrombotics? Which antithrombotic medication is my patient taking? What is the bleeding risk of the procedure? Is this procedure elective or urgent? And how do I stop and resume the antithrombotic medication? To answer the first question, these are the top five highest risk conditions for thromboembolic event. Bare metal coronary stents placed within one month. These are commonly treated with dual or triple antiplatelet therapy with thiopyridine and aspirin for a month, and then lifelong aspirin. Then venous thromboembolism within three months are associated with thrombophilias. Usually they are treated with medications called direct oral anticoagulants or heparins. Mechanical heart valves, like our patient, any mitral valve, some aortic valve, or any valve associated with atrial fibrillation. Recent coronary vascular accident or transient ischemic attack within three months. These patients are usually treated with Warfarin. Patients with drug eluding coronary stents within 12 months, again, treated with dual or triple antiplatelet therapy for 12 months, and then lifelong aspirin. And non-valvular atrial fibrillation. These are graded with the CHAT-VASC index, which takes into account multiple comorbidities, patients, age, and sex. And if the index is greater or equal than two, it's considered high risk. And usually treated with direct oral anticoagulants or Warfarin. If your patient falls in any of these categories, talk to the prescriber provider. Do not make any decision before discussing the case. However, I will try to drive you through what the current practice is. So which antithrombotic medication is my patient taking? These are the most common antithrombotic medications prescribed. Warfarin is a vitamin K antagonist of clotting factors. And the duration of action is typical five days. Direct oral anticoagulants or non-vitamin K antagonist oral anticoagulants. Dabigatran, Apixaban, Rivaroxaban, Edoxaban. They block the clotting factor 10A or Dabigatran. It's a direct thrombin inhibitor. The direction of action will vary, and it depends a lot on the clearance of creatinine. Aspirin, we know, blocks the cyclooxygenase inhibitor. And the direction of action is about seven to ten days. Theanopyridines, very commonly used. Clopidogrel is one of the most commonly used. Prasugrel and Ticagrelor. They bind to the P2Y12 component of the ADP receptor in the platelet. And the direction of action is typically five to seven days. And now the heparins. On fractionated heparin, given IV, it's very short acting, two to six hours. And given sub-Q, it's 12 to 24 hours. And the low molecular weight heparin, usually the duration of action is 24 hours. Now, specifically with the direct oral anticoagulants, these have very rapid onset of action, one to four hours. Rapid offset of action, about 24 hours. The Dabigatran specifically is mostly excreted by kidneys. The other ones, not so much. And well-given, they do not need bridging. The RE-LY trial with Dabigatran showed that bridging this type of medications will increase risk of bleeding with no benefit on cardioembolic events. There is only one condition that you will consider bridging these medications, and is if after a procedure, you think the risk is very high for re-bleeding, and you cannot resume them within 48 hours, that's when you're going to use heparin to bridge. In order to stop the medication before the procedure, again, it's very important the creatinine clearance. Anybody with a normal kidney function, you will stop them 48 hours before the procedure. Specifically for Dabigatran, if the kidney function declines, you will need to stop it either three or four days before the procedure. And if they are in case of end-stage renal disease, these are typically contraindicated or not recommended. In case of very high-risk patients like ours, the one that we are describing today, these are the typical conditions that will need heparin bridging. Prosthetic metal heart valves and mitral position, prosthetic heart valve and atrial fibrillation, atrial fibrillation and mitral stenosis, and within three months of a venous thromboembolism. There is no difference between unfractionated heparin or low molecular weight heparin in order to bridge. Now, back to our case. We already know that the patient is very high risk of a thromboembolic event, and it's here for a screening colonoscopy. Shall we do the procedure? Shall we delay this procedure? In order to answer this question, we need to ask ourselves, what is the bleeding risk of the actual procedure? So overall, any diagnostic procedure, like upper or lower endoscopy, enteroscopy with biopsies, is considered a very low risk for bleeding. ERCP without a sphincterotomy, EUS without FNA, APC ablation, Barrett's esophagus ablation are all low risk. Everything else, you already know it's a high risk for bleeding. Now, our patient is here for a screening colonoscopy. So then, what do we do? In general, you will not discontinue the anticoagulants or antiplatelets because it's low risk. There are endoscopies who will consider screening colonoscopies like a high risk procedure because 20 to 30% of patients can have colon polyps. But this is your own decision making. Now, is this procedure elective or urgent? This is the next very important question we need to ask ourselves. So for elective procedures and the patient on short term antithrombotic therapy, for example, in venous thromboembolism, we know it's three months, and bare metal stents within one month, we will defer the elective procedure if feasible. Now, in case of long term antithrombotic therapy like our patient, we know non-bivalent atrial fibrillation, mechanical heart valve, and drug eluded culinary stents, we will consider the cardioembolic risk before making a decision of stopping the medication. For example, interruption of aspirin carries a threefold increased risk of cardioembolic events, 70% occurring within seven to ten days. In general, try to not stop cardioprotective aspirin in any situation. Moreover, in case of dual antiplatelet therapy, one of the most common anti-regimen in the United States, the median time to coronary extent thrombosis after discontinuation of both medications is seven days. Whereas, the median time to stent thrombosis after discontinuation of the thianoperidine only, like clopidogrel, while continuing the aspirin is 122 days. So, stopping thianoperidines can be safe as long as we do it within the recommended time. This table, you will have it in the handout, is the best practice management of dual antiplatelet therapy. Overall, try to defer elective procedures to more than 30 days for a barometal stent and more than 12 months for drug elutant stents. Now, back to our patient. You decided to do the colonoscopy that day, and you obviously did not stop the anticoagulation. You found a two centimeter polyp in the descending colon. Now the question is, what do we do now? You finish your procedure, you did not remove the polyp because you already know that removing a polyp is a high risk for bleeding. You discuss with the patient the findings and the need for a repeated colonoscopy with polypectomy. Now, how do I stop and resume the antithrombotic therapy in this patient particularly? We know that colonoscopy with polypectomy already is a high risk procedure, and the risk for bleeding in patients not on antithrombotic medications is around 1%. The single most important factor that determines the risk of bleeding is polyp size. For every one millimeter increase in polyp size, the risk of post polypectomy bleeding increases by 9%. Other factors that increases post polypectomy bleeding includes choice of electrosurgical current, pure cut versus blended cut, age more than 65, the polyp morphology, and the use of antithrombotic medications. So for polyps less than one centimeter, a randomized control trial on patients on warfarin that had cold snare polypectomy versus standard polypectomy showed that in polyps less than one centimeter on warfarin, the risk of post polypectomy bleeding with cold snare is around 11%, while standard polypectomy is around 46%. The COP trial, which is clopidogrel uninterrupted post polypectomy bleeding trial, showed an increased immediate and delayed post polypectomy bleeding in patients on clopidogrel. The risk of post polypectomy bleeding holding anticoagulation decreases to 1.8 to 7% overall, and to date, there is insufficient evidence to endorse the cold snare polypectomy as the preferred technique in patients on antithrombotic therapy. So we will discontinue the anticoagulants and antiplatelets, except, again, for cardioprotective aspirin. How do we stop this? So our patient, he's on warfarin, and we already know he's a very high risk of thromboembolic risk. So you will stop the warfarin five days before the procedure, and this patient will require heparin bridging. So the heparin, if it's unfractionated heparin, you will stop it four to six hours before the procedure. And if it's low molecular weight heparin, you will give the last dose one day before the procedure. You always have to check the INR, and you need to make sure the INR is less than 1.5. In case of the direct oral anticoagulants, we already said, it depends on the creatinine clearance. Aspirin, you will continue the aspirin, and thianopyridines, if it's monotherapy, you will stop it five days. And you can actually switch your patient to cardioprotective aspirin. And in case of dual antiplatelet therapy, you will continue the aspirin and stop the thianopyridines five days before the procedure. When to restart the medication? Warfarin, immediately after hemostasis is achieved. I know this sounds very wide, but that's what the current practice is. Basically, after the polypectomy, or within 24 hours after the procedure is finished. In case of direct oral anticoagulants, it's the same, and I will show you afterwards. Aspirin, not applicable. Thianopyridines, again. After polypectomy, or within 24 hours. Now, with direct oral anticoagulants, the rivaroxaban and edoxaban, you will start them at full dose next day after the procedure. Apixaban can be restarted the evening dose, immediately after the procedure that night, okay? Or when hemostasis is achieved. The Vegatran, usually the dose is 100 milligrams twice a day. You will start with half dose the day after, like the same day after the procedure, and full dose the next day after the procedure. In case of polyps greater than one centimeter, again, you will discontinue the anticoagulants and continue the antiplatelets, except for aspirin. The same way you will stop them, the same way you restart them. The caveat here is when you're gonna do EMR of a polyp, endoscopic mucosal resection of a polyp greater than two centimeters or any ESD. Also applies for EMR in the gastric cavity or ampulectomy. So in this case, you will hold the aspirin, provided the benefit outweighs the thrombotic risk. And the total duration should not exceed more than seven days. And you, of course, will communicate with a prescribing provider. This is a table, it's on your handout that just summarized everything I just said. So you remove the polyp and block and there was no bleeding. Now, the question is, to clip or not to clip? So data is mixed with regards to the efficacy of prophylactic mechanical hemostasis after polypectomy and patients on antithrombotic medication. A recent meta-analysis with more than 2,400 colonoscopies showed benefit of clipping polyps greater than two centimeters. And in the proximal colon. Overall, cost effectiveness of clipping decreases when you have to use more than one clip. You are one week later at home after dinner and you get called informing that your patient is in the ER with hematochysia. He resumed the anticoagulant same day after the polypectomy. Patient is hemodynamically stable and there's a three gram acute drop in the hemoglobin levels. Despite adequate resuscitation, there is ongoing bleeding. Now, what do we do in this case? So, in case of urgent procedures or patients with acute GI bleeding on antithrombotic. If the patient is on Warfarin, it is safe to do the procedure if the ENR is less than 2.5, but you won't delay the procedure if the INR is greater than 2.5. You will hold the Warfarin and you will give a four-factor pro-thrombotic complex, or PCC, which has the vitamin K depending factors 2, 7, 9, and 10. Or you can also give fresh frozen plasma. You will give vitamin K, 5 to 10 milligrams, and be cautious because you can create a pro-thrombotic condition if you give too much vitamin K. In case of direct oral anticoagulants, again, these are very short half-life. And typically, the patient will be well just with resuscitation measurements. In case of hemodynamically instability, obviously, you will hold the medication. In case of Dabigatran, the patient can get hemodialysis or Idazucimab, which is a monoclonal antibody approved for life-threatening conditions that will go against Dabigatran. And in case of other oral anticoagulants, you can give four-factor PCC, factor 7A, or if the last dose was within three hours, activated charcoal. In case of antiplatelets, stop the medication, administer platelets. This is not consistent in all guidelines. The Asian guidelines are against this recommendation, sorry. And if the patient has a peptic ulcer disease associated with aspirin, you will resume the medication on proton pump inhibitors as soon as feasible, and you will communicate with the prescribing provider. In summary, when doing endoscopy in patients on anti-thrombotic therapy, it is important to stratify the risk of bleeding of the procedure versus the risk of thromboembolic event due to temporary interruptions of the medication. The appropriate time of interruption and resumption of the medication will depend on the onset and offset of action of each medication. Always communicate with a prescribing provider before stopping anti-thrombotic medications in high-risk individuals. And as a general rule, resume the anti-thrombotic medication as soon as hemostasis is achieved, or as soon as feasible, to prevent a catastrophic thromboembolic event. As Dr. Nina Abraham says, there is no talk of war between the heart and the GI tract. The heart always wins. Thank you very much.

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