Hey guys, welcome everyone. Hopefully you can hear us here. We're at the ASGE ITT Center in Downers Grove, Illinois. Thank you for joining us virtually. We're gonna talk through a couple of different situations here, which the fellows who are onsite are getting to work through in our hands-on portion of the course. Fortunately, a lot of this stuff, I think you can probably still glean some good lessons from using them here. I have with me one of our fellows from Mayo Clinic, one of our advanced endoscopy fellows, Dr. Daniela Fluxa, and we're gonna talk through these different options that they're using in the hands-on course. We're gonna start with a colonoscopy trainer. It's interesting, in my own training, Dr. Christopher Thompson in Boston at Brigham and Women's Hospital has a really nice training box that he's built. Interestingly, that was just to try and do different tasks, to teach us as we are learners in endoscopy how to accomplish different tasks, how to do torsion and torque, how to use the big knob, how to use graspers, some of these tasks that we do in endoscopy. This, for the first time ever, is probably the very best endoscopy trainer I've seen for teaching some of the more specific skills of colonoscopy. So this is something that your programs can actually purchase from Fujifilm. This is a wonderful trainer, which is adaptable. It's a digital trainer, which will actually score you. So talk to your program directors about whether this would be an option to bring into your program. I'm really excited about it. I'm really impressed. This is gonna have lesions that you can target. It's gonna have different levels of difficulty. So it'll create sigmoid strictures and other things that make a colonoscopy more difficult. And it really just is a great all-around training tool. So we're gonna start today's program with this training tool. And then we're gonna take a brief intermission. We'll stop for about five or 10 minutes. Please, please stay with us, stick with us, but go get a drink from the fridge. Take a short break while we set up our stomach, which is gonna be the model that will serve for all of the rest of the skills, hands-on skills that we're gonna work through today. That's gonna include things like coagulation therapy or thermal therapy. We're gonna talk through use of clips, through the clips. Banding. And I think we'll touch base on polyps as well, polypectomy. So a lot of good stuff coming after this short intermission, but for now, join us. We're gonna actually take a look and we'll switch over to the endoscopic view here in a second. Danielle and I are gonna continue to talk while she's doing this endoscopy about how you should approach colonoscopy as a learner, as a first-year fellow. We'll try and give you a few tips and tricks as she goes through this procedure. And then also for sure, take a look at the trainer, see what you think. Again, I'm impressed that it's about as lifelike as any trainer I've seen. Yeah, this is actually the first time I've seen it and I'm very impressed. It's pretty similar to what you'll experience. So I'm very impressed with this model. So we're gonna switch over to the endoscopic view. You're gonna see what we see on endoscopy. Yeah, and I wanna, you know, you wanna make sure, keep your ergonomics, make sure your scope is on the table. We'll take strains out of your hand. You know, ideally the table should be a little bit higher up for my height. But you know, things to keep in mind when you're starting. Make sure that you're comfortable when you're doing the procedure, okay? That's a great point. You know, you develop your habits now. So if you don't learn some of these things about ergonomics as a fellow, you're probably not gonna integrate them into your practice or it'll be much harder to do so. So Danielle made the point that probably she would have this usually like the table at about where your hands would rest on it, just a little greater than 90 degrees. So ideally this table would be a bit higher. It's not adjustable for us at the moment. We don't wanna mess up our video set up here, but having that table at a proper height is important. Having the screen straight ahead of you. We're looking into a camera today and you'll see a very bad ergonomics where Danielle is actually cranking her neck all the way to the right to see her endoscopy screen. But working towards a neutral head position, a neutral body position with endoscopy. Look, this is something you're gonna do thousands and thousands of cases over your career. It's important to take care of your body. We're realizing that more and more every day. Another point, when I started, I didn't have the light of my scope on. So make sure that your light is on, that your air is off, that you have your CO2 on, those kinds of things. You wanna make sure everything's set up before you start. Great tips. So we'll start with the colonoscopy. Every person has a different technique. Some people prefer CO2 insufflation. Some other people may prefer water immersion. For female patients that have had surgeries or they have patients that are older and may have severe diverticulosis, sometimes CO2 insufflation may make things a little bit more difficult and then water immersion may help you. So things to keep in consideration when you're doing this. I'll remind everyone in the audience, please feel free to type questions. So I'll be watching for questions for either of us throughout the session. So if you type in questions and submit that to the Q&A, we'll do our best to keep up and answer those questions as we go. So I already went through the rectum. Some people prefer to retroflex when they're performing the insertion of the scope. Everyone's different. My preference is at the end, but again, everyone's different. Some people prefer the other way around. So the other thing to be cognizant of is make sure about your loops. So usually by the time I get to the sigmoid, I'm very careful about it. I try to be very cognizant if I'm forming a loop or not so that as soon as I exit the sigmoid, I can reduce it. So Daniela made a great point early on that different attendings are gonna have different styles and ways to do things. I'm curious how you handled this when you were learning, but I'll say adapt to your attending, try different things. Fellowship is the time to try different ways of accomplishing the same clinical task. And then you get to decide in three or four years, whenever you're done with your training, you get to decide how you're gonna implement those different ways of doing things that you learned. So how did you handle that? If maybe you started to develop a preference, man, I really love water, submersive colonoscopy, but this attending wants me to do CO2, how do you balance that as a fellow? To be honest, as a first year fellow, I just took whatever the attending told me. As I was going through fellowship, I would ask the attending, hey, I think I prefer water immersion for this case. Do you think, would you be okay with me using water immersion? Some of them may say, well, I really prefer CO2. This time I would prefer that you use CO2 or sometimes they'll tell you, yeah, I'm okay. You're a second year fellow, you're a third year fellow, you should go and do whatever you want. So a point here, so I'm getting to a point when there's a kind of like a turn in which it's a little bit difficult to navigate. Never push when you're not seeing, just take a step back, see where you're going. I see the lumen is kind of going this way. So then again, don't push here. I'm just twerking a little bit to see if the lumen opens up, but I'm not pushing ever against resistance because I don't wanna create a perforation or a bigger problem. And as you go in, you may see lesions as you go in and you can see this lesion right here. Again, sometimes when there's these tiny lesions, tiny polyps, you may want to remove them as you go in because when you come out, it may be difficult to find them again. So again, another thing to keep in mind, just always show you attending. I see this, this is not normal. What do you think about this lesion? Help them teach you how to characterize these lesions. And again, sometimes when they're small, you'll remove them as you go in. There are different quality metrics in colonoscopy. So you maybe have heard a little bit about withdrawal time or insertion time, prep quality. These are all quality metrics that we use to figure out how we're doing both as a practice, are we referring the right preps and giving our patients enough information to have an adequate colon preparation for a high quality colonoscopy? But we also think about our own quality, the performance metrics like insertion time. So you're attending in that situation, I agree, I'll often remove polyps on my way in if I see them. You may have an attending who's very right in saying, it's a quality metric to see how quickly we can get to the end of the colon. And that's true, we will work our way towards the end of the colon fairly quickly. We're all under time pressure and then we'll spend a lot of time, the majority of our time on the withdrawal. And that's where we're looking for a minimum six minute withdrawal time. That's been associated with improvements in survival from colorectal cancer, improvements in adenoma detection rate and decreased interval cancers. So here you can see we're navigating another kind of tight, twisty, turvy part of the colon. I'll just encourage all of you, first year, definitely first couple of months of fellowship is not the time that you're gonna be intubating the cecum. And I think one of the lecturers earlier today made note that if you are reaching the cecum during your first month or two, I would argue actually some people are just really gifted. And so maybe you're one of those gifted endoscopists, but also it's probably an accident or it's a strange anatomic abnormality. I remember my first cecal intubation was a patient, I was really proud of myself, but I had missed that they had had the majority of their colon removed, so they had a segmental colectomy. And so the cecum was a very short distance from the initial intubation. So don't get me wrong, take the wins when you get them, but don't expect that you're gonna make it to the cecum every time. Here, we've just reached the cecum and we're looking for different landmarks. One of the things that is another quality indicator is taking certain photos along the way. So in the cecum, we'll wanna get a nice picture of the entire cecal base, which we have here that includes the appendiceal orifice. That's the little opening ahead of us, straight ahead here. And then that's gonna give us some clues as to where the TI, the terminal ileum is. I think this trainer's nice. So this is set up to be a fairly easy colonoscopy, but again, it can be modified. And then you'll see here when you get the TI intubation, there's a little note for you that says good job on the inside, kind of a cute addition from the Fuji team. So here we're in the cecum. This would be a place to look for polyps. We're looking all the way around using the full view of our camera. You'll definitely have attendings or consultants who give you advice that the goal is to move quickly, but to be smooth. So a camera, an endoscopist who's jumping around with a shaky frame of reference is someone who probably is gonna lose the scope, is gonna hand that over to their attending faster than someone who has sort of smooth, nice views. You don't wanna sit in one place for long. I think all of us, when we're first intubating the TI, when that's a new thing to us, we'll sit there and look at the villi for a while, and that's great. But at some point, it's time to move on with the procedure, and that's where we'll start our withdrawal. And I would say some of the tricks to going to the TI, you can deflate the cecum, so take some of the air out, and then you can kind of prompt into the opening. Sometimes it doesn't wanna open up. You can use some water or a little bit of air, and then eventually you'll go in. One of the other things that I did not mention is as you go in and reducing your loop, you may need to also deflate the colon a little bit, and that will help you sometimes, but with drawing, move forward, actually. So again, some techniques that you'll learn as you start doing colonoscopy and as you go through, you'll get the feeling on when you should reduce, when you feel the looping forming, when you should kind of deflate, and play with your torque. But again, try to keep your scope straight in this kind of like C formation. Again, this is just ergonomics so that you don't hurt yourself. For any of you who are gamers or are highly competitive, again, this trainer is really neat because it's gonna score you. It's taking measurements from how quickly you move through the colon, the different segments. You can both move too fast and too slow, right? So you want a certain amount of time you're spending in each segment on the withdrawal. You want a certain amount of time that you're not spending on the insertion. That should be a fairly rapid part of the procedure. And then how you're identifying different polyps. So I could see this would be a neat addition to like a GI medical jeopardy where you could also have a bit of an Olympics or a hands-on portion to a competition within your fellowship. We had a question, what are your thoughts on stiffening your scope? What do you think about that? Yeah, so I usually stiff... So first of all, I make sure that I don't have a loop. Once, if I feel and I notice that I'm creating this loop constantly, then I would stiffen my scope and see if that would help me get through. Sometimes stiffening the scope doesn't help and then I may need to ask for some pressure from my tech or my nurse. But I always try to first stiffen the scope and see if that will help so that I can spare my nurse or my tech from doing some pressure, which is actually very tiring. Yeah, so stiffening of the scope refers to these cables that run the length of the entire endoscope. So the shaft of the endoscope can literally be stiffened and that's gonna help prevent loops and loop formation. I'd say this is something you'll experiment with if you're attending. I personally use scope stiffening. I do like that. An older generation of Fujifilm scopes, for example, like the one we're using today is one of the newest generation, but some of the older generations didn't have stiffening. And so you certainly will have consultants or attendings who are used to not having scope stiffening. And so I don't think it's 100% necessary. It is a little bit of a crutch. It is an aid and does help prevent loop formation in the colon. We had another question about the difference between a PCF and an adult colonoscope. How do you think about those? So again, this is an endoscopist preference, I think. The PCF, it's more flexible. I usually tend to use the PCF for patients who have had previous pelvic surgeries or females or patients who have a low BMI. And I tend to prefer adult scopes for larger BMI or men in general. But again, this is more like an endoscopist preference, I think. Again, you'll try different scopes throughout your fellowship and you'll get the feeling and know which one works best for you. Again, the PCF, I feel it's a little more flexible. So it's a little bit better on my hands because I need to put less pressure to do torquing. So from an ergonomic perspective, I like it better. But it also loops a little bit more on some patients. So then I know I'm gonna be torquing more in those patients who are trying to reduce that loop. Which at the end of the day may counteract that flexibility. So it's really, at the end of your third year fellowship, you'll get to know which one is your preferred scope. I don't know, what's your thought on that? That's great advice. Yeah, I was gonna say, I've moved, I probably started using mostly adult scopes for colonoscopy and that's probably because there is a little less loop formation. And then over the course of my career, I've moved very much towards using PCF as my primary go-to scope. A little more flexibility, a little more maneuverability. The one downside I'll say, and I hope Fuji and some of the other companies will think about renaming the scope. When my patients see that I used a pediatric scope for their colonoscopy, I find that the women tend to like it. I think it implies they have a petite colon maybe. And my adult patients that are male tend to, I've actually gotten some emails like, hey, why'd you use a pediatric scope for me? And you have to explain then that it's just a standard colonoscope but a little bit smaller. So, and I was gonna say, so as you go, look for different type of lesions. You can see this type of lesion is very different from this one. So be very careful. Sometimes polyps may be hidden by like a mucus cap. So try to wash those areas, take a good look. Because you may, under the mucus cap, you could lose or you could not visualize a sessile serrated polyp. So just be careful, take your time to inspect. Try to look behind every fold, twerk side to side so that you don't miss any lesions. So really slow but intentional movements. So I've definitely had, I remember some of my mentors in endoscopy said, you should always be moving. You don't wanna move quickly, but you should always be moving in colonoscopy, always working your way out. You have a few more patients usually in a given day waiting for you for their colonoscopy. So you gotta keep going, gotta keep moving. Every case is an opportunity to learn. There's no question about it. Study these lesions like Daniella was saying. Good opportunity to learn and start to teach your eye for different types of lesions. Your consultants will probably impress you in that they will pick up on things that you just didn't think were possible to see. So sometimes a little bit of mucus that's on one part of the colon can be a mucus cap on a polyp. There'll be hidden lesions and different things you need to train your eye to look for. So always paying attention. The final thing I'll say in regards to that, listen to your consultants, listen to your attendings and make use of their advice. Watching them do endoscopy is sometimes as valuable as you doing endoscopy, especially early on. Watch your attendings body mechanics, watch what they're keeping in frame of view and reference on the camera. Those are all good things to see. You can emulate how they are performing their procedures. We have a new question around, when did you find, this is a good one. When did you feel like you finally stopped the death grip on your scope? Torquing has been much more difficult than what I initially thought. Yeah, it is difficult. I remember that my first week as a fellow, I ended up with like wrist pain from like the death grip. I think it gets better over time. I don't know exactly when I stopped doing the death grip. Probably, I felt more comfortable with endoscopy during my second year for sure. I would say maybe my second year, I was feeling much more comfortable with endoscopy in general, but also having less injury from have death grip scope or standing in a weird position, trying to look over the screen. So I would say by your second year, you'll feel much more comfortable with endoscopy. And definitely by your third year, you'll basically be almost independent. Agreed. Do you use a washcloth or anything in your right hand? So yes and no. Sometimes I don't like it because I feel it takes some of my feeling of the scope. But for withdrawal, I do use it sometimes just because I feel like the scope may be kind of like slipping. But I usually try to avoid it just because I do feel like it takes some of my sensibility of how much I feel and get that feedback from the scope itself, especially for insertion. Great. So then the withdrawal is all about identifying pathology on your way out, taking biopsies if need be. And then at some point, we're gonna make our way back here. We're at about 35 centimeters. So we have just a little bit to go, but we're working our way down into the distal colon. When we reach that point, Daniela was saying earlier, she likes to retroflex at the end of procedures. I personally was trained, I learned a lot of my procedures using conscious sedation. So the patient was usually at their best level of sedation at the beginning of the procedure. So I do tend to retroflex because of that practice pattern. I tend to retroflex right away while the patient is deeply sedated. Also, sometimes if you are under a MAC anesthetic, propofol anesthetic, if the patient's having apnea, it's a stimulus that'll sometimes help with getting the patient breathing. So I do tend to retroflex right away, but there's no rule there. Again, I would try the different ways that you're attending suggest, and then you can decide for yourself what you like the most. How do you retroflex? Yeah, so I was gonna go there now. So I go at the very end of the rectum, right? So I make sure I've examined all of the rectum in forward view first, which is right here, right? And then once I insufflate the rectum, make sure it's wide and open, and then I bring all of the big wheel up. Oops. Okay, so here, open rectum. Bring my wheel up and gently push forward. Very gently, you don't wanna feel any resistance. And then we have a little bit of fluid here, a little suction, and then you can see here my scope. Then I grab it with my pinky and move my right wheel to the right so that I can maximize my view. And then I pull the scope towards me so that I can get a good view of the dentate line. And I try to rotate the scope as I do that as well so that I can get a full 360 view of the dentate line, which here is not working very well. Using both of those wheels to really maximally retroflex the scope. And I think of it kind of like launching off of a ramp. So you'll insufflate, distend the rectal vault, and then you can use the first fold to kind of serve as a ramp to launch yourself backwards through that retroflexion, get these 360 views, which again is important for ruling out those proximal most polyps and masses, identifying any anal cancers or other things in this area. Really important. So we're gonna take a brief intermission here. We're gonna switch out our equipment and we'll be back with you in about five to 10 minutes. Thanks guys.

endoscopy training

colonoscopy techniques

Dr. Daniela Fluxa

polyp removal

ergonomics

quality metrics