Welcome and good evening. This is the American Society for Gastrointestinal Endoscopy. We appreciate your participation in our weekly webinar series, Thursday Night Lights. Tonight's presentation addresses polypectomy, commonly performed maneuver and colonoscopy with the goal of complete removal of the polyp. Tonight we will review common adverse events related to polypectomy, including but not limited to bleeding, pain, and perforation, and discuss approaches for preventing and managing these events. My name is Ed Dillard. I'm the Chief Publications and Learning Officer on staff here at ASGE, and I will serve as your facilitator for tonight's presentation. Before we get started, just a few housekeeping items. There will be a question and answer session at the close of the presentation. Questions can be submitted at any time online by using the question box in the GoToWebinar panel on the right-hand side of your screen. We look forward to your questions. Also the presentation slides are immediately available as a PDF file via the handout box in the GoToWebinar panel. Please look for that. Also note that this presentation is being recorded and will be posted in the webinars folder in GILeap, ASGE's online learning management platform. You will have ongoing access to the recording in GILeap as part of your registration tonight. Now it is my great pleasure to introduce Dr. Keith Osteen. Dr. Osteen is an active clinician with a focus on general gastroenterology. He conducts research in the areas of capsule robots, image-guided technology, new technology, device development, endoscopic training, and healthcare quality improvement. And, oh, by the way, in his spare time, he serves as Vanderbilt's GI Fellowship Program Director. So, it is my great pleasure tonight and ASGE's to introduce Dr. Osteen. Dr. Osteen. Thank you, everybody. Welcome to the webinar series, Thursday Night Lights. I appreciate the opportunity and the invitation to present in this format, in this webinar. Special thanks to Ed and Lyle and all the staff at ASGE who have made these events possible. And to all of you who have tuned in and taken your time on this Thursday night to come and attend this webinar and hear about polypectomy. So, without anything further, we'll continue and go from there. So, I think every good talk starts with what we're going to cover so that you know the highlights because there's a ton of material underneath this. But really, I think the highlights are what do you do with residual tissue at the time of polypectomy or EMR, bleeding, both immediate and delayed, and we'll go through different items like using clips or loops, as well as how to handle anticoagulants. And then discomfort after procedure, perforation. And then we'll talk about what to do with recurrent or residual polyps. So, let's just get started with residual tissue. So, here, how can we avoid incomplete endoscopic resection? And feel free at any point in time to post your answer in that questions box there. If you have a comment or you want to answer these questions. So, how can we avoid incomplete endoscopic resection? And so, there's several answers. First, you just need to visualize the entire lesion. So, making sure that you really clearly define how big the lesion is, what it looks like, use enhanced imaging techniques, white light, narrowband imaging, all certainly help. Other things from a mechanical point of view that you can do is really manage your insufflation. Make sure that you insufflate enough so that you gain space so that you can see where that lesion ends and begins, and if it goes over a fold. If it's challenging or you're not sure, always be able to reposition that patient carefully. Or you can use an assistive device such as a cap, and I have a clear cap there. It's very similar to your banding caps. It comes separately so you don't have to open up a banding kit to be able to use it. But clear caps can be especially helpful to just push down that fold that might be always in your way. As any of us who have done these a lot tend to find the most challenging situations when a fold pops up in front of you. So, it helps to bat it down so that you can see the entire lesion clearly through it. And then certainly, you do have the opportunity to retroflex. And so, in this video here that will play in a second, you can see we're doing colonoscopy here. The colonoscope is retroflex, and this polyp, which you see is here behind a fold. You can also see the edges of that clear cap around it to help us visualize the entire lesion. And using electrocautery, snare cautery, we've taken this lesion in block, and you can see the resulting area there. If you notice, also here in the background, and if I can take this here, we'll try to do this laser pointer. You can see where it was where we had the endoscope in the back looking in retroflexion. So now that you've done your best to snare as much of the polyp as you can, some remains. So what do you do? Do you get more? Do you ablate? So if you do take more tissue, your options are a couple. You could try to snare some more, or you can use biopsy or hot avulsion, and we'll go into that in a little bit. Or ablation, snare tip, or APC, argon plasma coagulation. And so when would you need to remove more tissue? You would need to take more tissue if you're really suspicious that there's an underlying malignancy that's there. And really what I would encourage you to do is instead of sending it in that same jar that you sent sort of your larger portion, or let's say your piecemeal resection, if you're concerned that there's an area on the outside margins of where your polypectomy was and you want to take more tissue, I would encourage you to send that in a separate jar. And the reason is that way you know if that tissue comes back normal, that you've gotten the entire lesion. But if it comes back AB or normal, abnormal, then you know that you haven't sort of successfully completed the entire resection present there. If you just put everything into one jar, it's hard to discern if you actually got the whole thing or not. So if you're going to go back and take additional tissue because you were concerned about some of the margin or an area of foci after your sort of polypectomy, I would encourage you to put it in a separate jar. So what are reasons for that the polyp doesn't come off? Why do you still have some residual there? So one of them is partial snare polypectomy. The snare sort of goes on as it's grabbing tissue. Maybe it folds up. Maybe it's across a fold and you get some residual there that then tends down. Tattoo. In a lot of cases, tattoo will cause a local inflammatory response and cause some scarring. Usually this happens when somebody tries to do their best to help facilitate removal in the future and decides that they're going to inject tattoo, let's say, two folds before or after where this polyp is and then send them to you so that you can try to resect it. Well, actually, a lot of times that tattoo, even though you're two folds away, might actually be closer than you think. And it has been known to track several folds in advance. So there have been cases where that tattoo, even though it might've been injected 10 centimeters away from a lesion, has sort of gone through that area and caused a local scar area so that that polyp will no longer lift. The other thing is, and avoid this, if you don't have plans to take out a polyp, don't biopsy it because biopsying, again, will create a local inflammatory reaction in there and cause scarring to go down so that now you have an area that's sort of tented. It won't raise and lift because of the biopsy effects. So if you see a lesion, you don't feel comfortable taking it off at that point, or it's not the right time, the patient hasn't gone through sort of the full risk and benefits because you think you're going to do an EMR, which has a little bit higher risk of adverse event involved, always bring them back. Do not sample it. I would not inject solution around anywhere in that vicinity or that area. You'll be able to come back, photo document, count your folds, and come back for another time to avoid failure to lift. And then the location of the rectum also tends to have more areas where that polyp won't sort of go up well with a polypectomy lift. Moving on. So you've removed this polyp here, and you see this at the polypectomy site. Any thoughts on this? And I'll give you a second. Again, if you want to type it in, in the questions box there, that would be helpful. So in looking at this, and I'm going to try to bring up the pointer here. It's just clicking through, which is okay. So we'll go back. So it looks like there's a little bit of residual tissue there right in the center. You've done a nice job on the side margins here, but right in the center, you still see a little pink area that's elevated and raised. And so you probably need some more tissue in that specimen there. Try to take that off. So option, you know, could you use argon plasma coagulation? Well, certainly we know that argon plasma coagulation around the margins of a polyp, especially over 15 millimeters, does tend to reduce the risk of polyp recurrence. So a lesion that's over 15 millimeters, even if you take it off in block, you should still APC around the margins. And this applies for things 15 millimeters or larger in size. It was a small randomized trial, but it was a good one. And so the risk of recurrence at that point was 10%. With no APC, it was around 64%. Subsequently after this publication, there's been multiple other studies that have also supported this, including getting the edges with soft tip, snare tip coagulation as well. And so what are some of the technical details? I get a lot of questions about this. The technical details for this APC are going to be 30 to 45 watts, argon and about a liter. And you want to do it in short bursts. You don't want to sit there and paint like you would for something like GAVE or radiation peroctitis. It's really just a couple of key short blasts, get it a little bit brown around the edge and keep moving. And then you really want to try to avoid getting that muscularis. And that just helps to avoid transmural thermal injury and potential perforation. Again, remember, APC isn't meant to go very deep. It only goes about one to three millimeters in depth. So if it looks like you have more tissue that's still there, you're probably going to need to use a different technique like biopsy or avulsion. So here we can see a lesion. We've taken this off here and there's a little tiny nub there and application of APC. Again, APC is a non-contact therapy, meaning you don't have to touch and you shouldn't touch the tissue that you're trying to get with the probe. You should probably be around a millimeter to two millimeters away from it. And that arc is what'll carry that electric current and allow your char feature. Remember, it does put in argon gas, so you're going to want to maintain visualization of your lumen and suction appropriately to suck out that gas that you put in to potentially avoid barotrauma. So the take home messages for APC use. Large lesions, make sure that you get around the margins of your polypectomy site. It reduces the rate of recurrence. Certainly in piece neopolypectomy, either touching up those margins, as I said, or little sort of tiny islands within that area. Know your settings. If you're uncomfortable or unfamiliar with their settings, there's always representatives who are happy to help. There's always others at your institution who would be happy to help. I would encourage you to practice with it before you go in. Certainly, the opportunity is there to even use different food products like bologna or other things and almost do your own ex vivo lab at some point to really become familiar with your settings and how to use it. And then avoiding that muscularis layer. So bleeding. So post polypectomy hemorrhage is defined as a lower GI bleed that requires transfusion, hospitalizations, some other intervention or a surgery. The incidence is anywhere from 0.3 to 6%. And it does change based on technique used, patients on different anticoagulants or not, the size of lesion and location. And I'll get into that in a minute. So the timing, it can happen anywhere from immediately, right? You do something, let's say cold snare polypectomy, and it's still losing after about 30 seconds, 45 seconds. That's an immediate bleed and you can handle it there up to even a month later. And so your treatment is going to be typical as it is for your other gastrointestinal bleeds. Injection, thermal, you can use clips, but occasionally it does require IR or even surgery. So this is going to be another video here. So are the delayed risks, sorry, the slides are advancing a little slow. I think it's just the internet routing from the cloud. So please bear with us. There are other occasional risk factors or what are the risk factors for delayed bleeding? And so you have patient characteristics and polyp characteristics. So this patient characteristics, you could probably guess, right? Age and as people get older, especially beyond 65, the age incidence increases about 4% per year. Patients with hypertension and certainly patients who are on antiplatelet or antithrombotic agents. And then when we look at polyp characteristics, so seagull polyps tend to bleed more. Again, that wall is thinner, which means that the blood vessels that are there are going to be closer up to that surface area. Larger polyps, so above a centimeter for each sort of millimeter you continue to go up, the bleeding risk does increase. Thick stock. So these are your pedunculated lesions. So a stock that's bigger than a centimeter is certainly going to have higher risk than stocks that are less than one centimeter. Larger polyp is malignant. And again, that's just from the vessels that run into it or feed that. So bleeding, so in an EMR of 101 lesions in 92 patients using a variety of techniques, there is a significant association. I think this is shown in here just to show you how significantly the bleeding risk goes up based on lesion size, right? Pretty low for lesions under two centimeters. Once you start getting a little bit bigger than that, now you're looking at approximately 25% and even over 30% for a three centimeter lesion. So how do we prevent it? Is there a role for prophylactic clipping to prevent delayed post polypectomy bleeding? Let's see. So this is a randomized control trial, 413 patients, approximately 200 with clip placement and 200 with no clip placement. And as we can see here, there really wasn't any significant difference between those who got clipped and not. But what I really want to point your attention to is that these were smaller lesions. These were on average about eight millimeters in size. So then you would say, rightfully so, well, what about bigger lesions? Tell me about sort of these bigger ones. And so there's plenty of additional trials involved there. This one is of another 463 patients. This was looking at pulps that were larger than a centimeter in size. And you can see there was a difference between clip and no clip based on size and your technique there. Now you can say maybe left side versus right side, but if you look at the confidence interval on there, it does hit one. So here's a lesion that's raised. You can see we've injected a solution here. And the real question is, would you clip or would you not clip this lesion? And I'll give you a second to think about that. And so really your answer should be, well, maybe. It's a case by case basis. So if the lesion is large, and we said certainly, you know, if it's over two centimeters, you might strongly consider it, but not every time. If you do see a visible vessel or pigmented protrusion in the base, you're going to want to clip it. If you have to resume anticoagulation on that patient or an antiplatelet agent within the week, then I would encourage you to think seriously about clipping it and close that area. And then certainly a patient who can't tolerate bleeding. And these are the patients that either live really far from your medical center or an emergency department, should they have a bleeding event, or patients who wouldn't be able to tolerate it. Let's say they have aortic stenosis or another condition that's really dependent on not being anemic and their volume status. So what do we do about anticoagulants? Well, it's the balance between the risk and benefits of bleeding. So this rubric here is based on manifrin. So aspirin, NSAIDs, you continue. We take off polyps all the time on aspirin. The heart wins the battle in this one. So do not stop aspirin for these patients. The next one that we look at is going to be antiplatelet agents. So hopefully this will come up here. There we go. So this one here is clopidogrel or thioperidine antiplatelet agents. So if the thrombotic risk is low, then you can discontinue it. If the thrombotic risk is high, then maybe consider discontinuing it. I will tell you though, more recently, there's plenty of literature out there that does support continuing some of the antiplatelet agents, even with cold snare polypectomy. So those are typically done for lesions that are less than one centimeter in size. I will certainly feel very comfortable taking off polyps one centimeter in size and lower while somebody is actively taking aspirin and clavix. When it comes to things like warfarin, then you, again, have to discuss the thrombotic risk, low or high. So if it's low risk, certainly discontinuing it or holding it for a brief time is reasonable. If the thrombotic risk is high, this would be somebody that you have to seriously consider bridging and bringing them into the hospital either for heparin or managing it as an outpatient with their outpatient provider to get them through the procedure safely without additional sort of impact on the condition that they're treating with the antithrombotic. So the take home message is prevent bleeding. So always, always, always look for the signs of bleeding after you take out your polyp. So you're going to want to look and make sure there's no oozing. If there's oozing, don't just say, oh, that'll stop in 30 seconds or, oh, that might stop in a minute. Watch it until it's done. Make sure that it's not bleeding and then wash it off and make sure it doesn't start re-bleeding. Treat any active bleeding. And again, if you see visible vessels, treat them. So moving on here, are there other methods that we can do to reduce the risk of bleeding? So this is where detachable snares come into play. And this video here on the right, you can see is one using a detachable snare on a large pedunculated polyp. So again, if the polyp, I don't know, pedunculated polyp is two centimeters or larger. If the stalk is one centimeter or larger, the risk of that polyp bleeding is very significant. And really you should be using some additional method on the stalk to try and tamponade those vessels prophylactically before you take it off. Endoloupes can be scary. And I think the reason why they're scary is they're not fully intuitive. So you really have to practice that with your tech over and over again. And I would encourage you to do that if you're going to use it before you put it down. The other thing and why they're scary is you can ligate or you can do a polypectomy with the polypectomy loop, but you don't want to because one, that wasn't your goal. And two, then you're going to get bleeding and you're going to get a red out and it'll be a nightmare. So if you're going to use a loop or a detachable snare, I would encourage you to practice it before you get in there and do it. Make sure that you and the tech are very comfortable with it. You can, once you do the detachable snare, let's say you're doing it in practice session with like a pen or a pencil, you can reload it. So it's not like it's one and done. You simply can reload that back onto the platform, back onto the catheter and continue to practice again. So it's not like you're going to be burning through a bunch of these and raking up the bill for equipment that hasn't been used. The speed of cutting through the polyp, remember, pedunculated versus flat. If you just go through something really, really quick, even though you might be using electrocautery, you're still in a way taking it cold, because it hasn't had enough time to cause coagulation or cutting. And then again, do you strangulate penunculated polyps? And I gave you some guidance on that. If the head of the polyp is bigger than two centimeters, if the stalk is bigger than a centimeter, I would highly encourage you to do that. So again, this is an RTC loop polypectomy here. Where do you place the snare or the loop? I should say, you're gonna place that ligation loop down low close to where the stalk meets the mucosa of the colon. And then you're gonna take that polyp off between the base of the polyp head and above your loop. You're not cutting below the loop, but as you can see in this picture, they cut between where the polyp head was on the stalk and the blue loop. And the reason why you wanna do that is because that loop is what's really holding your vessels there. It's tamponading them almost like a tourniquet. If you cut below that blue band, it's almost like you never even put that loop on there in the first place. So where do you take it? You put the loop down low, right where the tissue of the colon is that comes up into the stalk. So on the stalk there at that area, and then you cut the polyp off between the top of the loop and the lower part of that polyp head, as you can see here in this diagram. So, oops, you have intraprocedural bleeding. Now what? Take a deep breath, check your pulse, make sure things are going well, and be very calm and go through it. You know how to handle GI bleeding. This is really no different. So you can use a combination of injection with epinephrine. You can use the tip of the snare. If you're gonna do that, I would encourage you not to push it out very far and be very mindful of where it is so that you don't inadvertently cause another adverse event such as a perforation. APC is an option, certainly electrocautery. And these are the grasper forceps or hemostatic forceps, and I'll go into that in a second, or clips. And you have a variety of options of hemostatic clips, including over the scope clips. So these are what hemostatic forceps or coagulation graspers look like. If you can see here, the difference between these and biopsy forceps is these are flatter and they have a larger surface area. So if you think about it from a mechanical point of view, when you put a charge onto these, it's gonna disperse that energy over a wider surface area. And so it's not gonna go as deep, right? And so in the picture on the right, you can see where the little vessels are up in the mucosal area, they're red, and that sort of pink fleshy band down there is the submucosa. And so if you grab it, you're only gonna get a burn in that mucosal layer and not very deep because the energy is being dispersed over a wider surface. So that's why these are different from like a hot biopsy forcep or just a regular sort of snare, sorry, a regular cold biopsy forcep. Again, they're flat, they disperse that energy for you. Here you can see in this video, what's nice about them, we have a bleeding vessel here after a polypectomy, you can go on there, you can clamp it closed and before you fire it, you can actually see if it stopped the bleeding. If it didn't stop the bleeding, you can simply open back up, reposition and put electrical current on it again. So they're nice in that regard and aspect. Again, you wanna try to stay away from the muscularis layer down there, but you can see just grabbing it, burning for a couple split seconds and going from there does a really nice job of getting those little feeder vessels. Here is clipped hemostasis. So we're taking off this larger polyp. As you can see, there's a clear cap around the end. This is using snare cautery. The polyp has been removed and we're gonna look at the base here. The base looks nice. It doesn't look like there's any problems and then all of a sudden, whoa, we have this bleeding area that's starting to come out. Again, check your own pulse, take a deep breath. It looks like it's bleeding fast, but it's not, the patient's not exsanguinating. You're gonna be just fine, manage it well. So in this case, you can either try to use the coag graspers or hemostatic clip. Depending on the clip that you use, some can open and close, some once they're closed, they're closed. If you have the ones that open and close, they're actually very nice because again, similar to what I explained before with those coagulation graspers, you can actually close the clip, but not fire it. And then you can see if you actually got that bleeding lesion or not. So here the clip is closed and we wait a second. We're gonna spray it with some water. Water's our friend here and we can see, oh, nope, it's still bleeding despite our clip close. So if we were to have deployed that clip in that area, it would have been a mess because we would have kept having to put more clips on that area. And as you know, your first clip is always gonna be your best placement and your best attempt at stopping something. So you really wanna make sure that that first clip is done well. And so here we'll try it again. We'll clip closed. Let's see. And it looks like it's still bleeding. If you look in the center of that coagulation forceps, so probably don't wanna close all the way there and fire that. So let's try one more time. So it's still bleeding. Again, it looks like a lot of blood. Remember everything is magnified in endoscopy. So check your pulse as well as the patient's and you're gonna be just fine. Here we go. Hopefully third time's a charm, at least that's what you're thinking. And here you can see we're insufflating. We'll spray some water in here. And you can see it has stopped. So now we'll fire that clip, we'll deploy it. We've deployed the clip. And then you always wanna look at what you did. Don't retreat. You wanna go in and check out your work. And so it looks here, I don't see any more bleeding on the side there. Certainly none coming from that area there. But that clip did the job because it was placed properly and well. So how do you decide, coagulate or clip it? Good question. So there's advantages and disadvantages of both. I think the advantages of coagulating is you can get multiple sites with one device, right? You can keep moving. One of the disadvantages, and I mentioned this is, again, potential injury to the muscularis. And then advantages of clipping are, you can treat a perforation or the injured muscularis propria at the same time as you're taking care of bleeding. Mechanical compression is very good. And so you might obviate additional ulceration as the tissue heals. One of the disadvantages is that it can sometimes interfere with continued interventions or therapy. So if you want it to continue on with your EMR, that clip might be in your way. So what about over the scope clips? They work like banding devices and there's a nomenclature involved in these. And so in case you're ever wondering sort of what all these numbers mean, the first one is the diameter of the object there or of the clip. The D, the second one is the depth. And so they usually come in two different depths, a three millimeter and a six millimeter. Obviously the six millimeter grab more tissue than the three. And then the teeth. And teeth have different shapes to them. Some are meant for compression. Some are meant for holding or fixating tissue and bringing it together with tamponade. And then others are meant to be used in the stomach only for like perforations. You use it for hemostasis, as I said, or perforation. And so let's go here. And this is a video where you can see there's a vessel there in the center of a lesion that we've taken off. This is nice because this entire area will fit nicely right in to this cap, which is like I said, very similar to a banding device. You can even see the string there on the lower left-hand side. So when you suck it in, you know it's a vessel because it's starting to pump. Now, when you get to here, I would encourage you not to release the suction because what happens is you're just going to drop that bleeding vessel and it'll be read out. You'll never be able to find it easily again. So once you get in there, you know it's there. You drop that over the scope clip and you can see it there and you fire it on nicely covering that lesion. One thing for those of you who haven't used the over the scope clips, you can always, again, practice outside the patient. Don't make it your first time using one of these with a bleeding vessel there. Definitely practice, gain experience and exposure. The other thing that I would encourage you to do is be prepared for recoil with these. As they drop down over that scope and clip, there's going to be a recoil back on that. So similar to how you do balloon dilations where you anchor your endoscope at the bite block with your one hand and then you anchor the catheter or the wire with your other hand at the therapeutic channel, you're going to want to really make sure that you're anchored to the patient well to avoid misfire when these recoil. So over the scope clips can represent and then do represent an effective endoscopic treatment for acute bleeding after failure of conventional techniques. And this was based on several studies. 30 patients, six centers was one of the larger ones here and hemostasis was achieved well over 95% of the time. I've put this in here so you could see it's used both in upper GI tract and lower GI tract. And in particular, if you look at EMR, primary hemostasis was maintained in the small study of all the patients in that group with five patients. So moving along, post-procedure pain. So this is the big and scary that we all have. So really asking questions about the pain. If it's dull, consider that they have had over distention. Maybe you put in too much air or CO2 or it was a prolonged procedure where sort of you found this big polyp and you weren't expecting it and you had extra time in your schedule and you were in there for like an hour. These are the cases that you really wanna think about distention. It happens more with air, much less so with CO2, but be mindful of that. If there's sharp pain, then you really need to consider strongly perforation or if you use any sort of thermal therapies, transmural thermal injury. So I really think the take-home message, and I have it here on the right in yellow, which is use CO2 and or manage air very well. So be very mindful. Insufflate only what you need to and then use suction liberally. And so really be cognitive of how much you're putting in and taking out. So if somebody has post-procedure pain, if you ever have any questions of what's going on, get a CT scan. It's better to get that CT scan and put the issue of potential perforation to rest rather than causing the patient undue harm or having you even stay up all night worrying about it. If it's gonna cause you not to sleep at night and the patient, you might even consider perforation, get the imaging. Make sure it's not that perforation, right? We own what we do. So if we took out that polyp, the adverse event is ours. Be confident in your management and own that and discuss with the patient. And so what about post-polypectomy coagulation syndrome? So there's some causes, right? It's usually local peritoneal irritation from thermal injury, a transmural thermal injury that irritates the cirrhosis. It ranges depending on different settings, how long you've sat there on your coagulation, anywhere from a half percent to a little over 1%. It can present anywhere from one day to five days after colonoscopy, and the symptoms are very similar to perforation, right? Fever, localized abdominal pain, some peritoneal signs and some leukocytosis. The difference is that you don't see free air on your imaging. So how do you treat it? Nilpiros, antibiotics, and then monitor them. Do serial exams, monitor for elevated white counts and fevers. They usually resolve spontaneously without surgical treatment or intervention. But if symptoms continue, sometimes these patients might need additional exploration. So what about perforation? So this is a problem, right? This is the oh moment. So you can see here the perforation. You don't want your pathologist to tell you on your polypectomy specimen, glomeruli appear healthy and normal. That's a problem. So recognizing it right away and managing it like a champ or key. And so how do we do that? So one, if you're gonna avoid it, you need to see the lesion completely, like I said at the beginning of this webinar, but really the lesion should lift. So if it doesn't lift, it means it's tented down to the muscularis, which means that if you take it, not only are you gonna probably get an incomplete resection, but you're also gonna resect muscle layer, which means you're gonna increase your risk and you're gonna perforate. So don't grab too much tissue, right? Don't try to be the superhero. Go in there and say, oh, look at that lesion. That's a three centimeter lesion. What's the biggest snare we have? And try to take it off in block with that. You're setting yourself up for a problem, right? Be mindful of the size of the lesion and understand that most of these lesions, when we do EMR, lower EMR, are gonna be taken in piecemeal fashion and that's okay. You can use a technique called grab and release. You have to practice this with your tech, but you're gonna grab that tissue, see what you got, shake your catheter a little bit and then have them just release just a little bit. The thought there is that it'll help to drop out that muscularis layer and then re-close. The other technique is when you grab it, as I said, shake your catheter a little bit. You can feel if it feels like it's tented down or if it's sliding freely. If it's sliding freely, it's more likely that you just have the mucosa layer as you want. So what does it look like? Everybody says the target sign. If you've never seen it, this is what the target sign looks like. Why is it a target? Why does that happen? So you can see there's blue dye in there. The blue dye takes up in the submucosa. It does not get uptake by the muscularis layer. So the muscularis layer will remain white while your submucosa will remain blue. And so you can see those areas there of white are your targets. On the top is the specimen, on the bottom is your colon. And so you have a mirror image of it on each, right? Because you've resected part of that muscularis layer that did not take up the blue dye. So there's different ranges of perforation from no leak at all, to an air leak, to a fluid leak, and then full leakage of everything, feces, et cetera. Certainly on the lower ones, so no leak, air leak, that clip closure, abdominal decompression, close it right away when you see it or recognize it. The later ones with fluid or feces are gonna require additional intervention by our colleagues. So you have an 80-year-old female with COPD and coronary artery disease who you're doing an EMR on and they develop acute distress. Their blood pressure drops and they desaturate. You've taken off that polyp, what are you gonna do? So obviously you're gonna panic, but you shouldn't because you're gonna manage this like a pro. So again, take a deep breath, check your own pulse, check the pulse of your tech, make sure the patient's doing okay. They're not because they're hypotensive and desaturating. What do you wanna do? If you wanna use the question and answer box, please type in your response. Don't worry, nobody else can see your thing. I might be able to, but you won't, and I don't know who you are out there, so don't feel like I'm grading you. So are you gonna increase the oxygen flow to 10 liters? You might, they're desaturating. Get a stack glucose? Probably not. Or needle puncture of the abdomen. You're like, oh my God, why, what's going on? Well, this is pneumoperitoneum, right? If you cause a hole and you're blowing a bunch of air in there, they're gonna get pneumoperitoneum. So how do you obviate this? You can take your needle, you can fill it up with some saline in there so you can see air bubbles, and you can put it into the peritoneal cavity after you clean the skin with a sterilization solution. And you can see the air comes out. Once you know you're in the right spot, after you've numbed that up, you can put an angiocatheter in and deflate the abdomen. And you just saved that person's life because you've obviated their pneumoperitoneum. And then at that point, you can look for your perforation and try to close it from the inside because this will stabilize and help to stabilize your patient. So what can happen? Immediate effect, as we said, is air leak. You can't maintain distension. So if you're in your endoscopy and you've taken off a big polyp, and the next thing you know, things go no space, right? You can't inflate. You say, what's wrong? Well, you check, make sure your CO2 is not out. You check to make sure everything's hooked up. You're still not able to see. Think about perforation. Fluid leak with contamination. This is why a good bowel preparation is really important. If you do have a perforation, but you've had a really great bowel preparation, there's less stool and stuff to flow out of that area. And then certainly, if you get cardiopulmonary compromise, think pneumoperitoneum. And again, it's a reason to really consider and strongly use CO2. But you're gonna manage it like a champ, right? So you're gonna stabilize your patient, do decompression if you need to, and then consider what options you have. Are you gonna use hemostatic clips to close it up? Are you gonna use an over-the-scope clip? Do you stop or do you continue your polypectomy or EMR, right? Just because you perforated, if you've managed it and you've managed it well, you can consider if the patient's stable again, finishing your job. Again, I wanna emphasize the importance of informed consent. Really helping that patient understand what you're doing and the risk involved with what you're doing. I think the better the informed consent is at the beginning, if or when you do have an adverse event, the patient is much more appreciative and much more understanding than if it was sort of out of the blue and it was like, oh my God, I didn't know that. Make your calls. Even if you don't think that the patient needs to be admitted, err on the side of caution. Admit them, watch them, make sure they're gonna do okay with the perforation. Call the surgeon. They don't need a surgery if you've managed it well and you've closed them up and you're gonna give them antibiotics. But it's better for that surgeon to know what went on and have it on their list or on their radar than to not be involved from the onset at all and get some emergency crisis call at 3.30 in the morning. Consider nasogastric suction and then your broad spectrum antibiotics. So here's a lesion we took off and this video goes through pretty fast, but this was the uh-oh moment. I think this is playing at super fast speed because there's no way I can put clips down that quickly in that fine of an alignment. But that was a perforation there. Let's see if I can get that to play again. Let's see here. Hopefully, Lyle, is there any way that we can slow this down a little bit? If not, I'll play it like six times for everybody. So anyway, you saw it taken off and for a split second there before the clip started blasting and everything there, you saw basically yellow. And so that was a perforation. That's the oh no moment involved in there. And so handle it like a champion. This was one of those cases where you can clip close it and the patient did extremely well. So moving on to the next slide. So colonic clipping. So what's the evidence for all this? So on review of 7,500 colonoscopies with 30 perforations, five went to surgery and 25 were treated successfully with endoscopic clipping. When comparing clips versus surgical management, clip closure resulted in a hospitalization of around three and a half days versus surgical management of around 12. So you can see there is a significant difference. Again, clip closure for perforations less than a centimeter inside is very, very successful. Reasons to go to surgery, foul closure, fecal contamination, the defect was too large, or it was just in a really terrible position. You just could not see where the area was, folds were in the way, insufflation wasn't holding, you just couldn't get a good perch on it. That's a fine reason also to go to surgery in that regard. Technically you could not get it. So what about residual or recurrent polyp? And so resection and recurrent disease. So with this, 15 patients underwent ESD after EMR, complete resection was achieved in over 94% of them. So what is this about? Well, if you've done endoscopic mucosal resection, you still have residual areas there, and there is concern you can always do endoscopic submucosal dissection to get a more complete resection. The risk of that is bleeding and typical, but there is no recurrence, at least in these small study. In another one, 30 patients, your goal is an R0 resection, that means complete resection. So if you hear people say, we want an R0, that means you've resected the entire thing. Bleeding risk up front was around 16%, but there was no delayed bleeding, no recurrence. And it was really good as far as a short-term cure rate. So to summarize here, while we all really strive to avoid adverse events, they are a consequence of anything that we do, of any endoscopic procedure. If you do enough procedures, you're gonna get them. So even in the most skillful of hands, even when you're most careful. So make sure, do good informed consent, make sure that you know the ins and outs of your equipment, and manage it really well. And so these keys, again, I know I've been repeating them, but I think it's really important. Be prepared, practice, be vigilant, recognize when an adverse event has happened. Don't just think if you ignore it, you see bleeding, you're like, eh, it'll stop and run away. Handle it, own it, take care of it. And then take a deep breath, right? When I keep saying check your own pulse, just take a deep breath. A couple deep breaths is gonna do worlds of wonder because not only will it calm you down and allow your dexterity to be better, but it will calm everyone in that room down. Because the second that they see blood or something else, we all know everybody's anxiety level rises. And you, as the endoscopist in the room, have the opportunity to show your leadership there and say, this is gonna be okay. Even though on the inside, you might be freaked out and say, oh my gosh, this isn't gonna go well. Just take a deep breath, set a tone of calm, and everybody else in that room will be calmer and they'll respond better. And your patient will actually be treated better and have a better outcome because of your ability to maintain the situation and control the team in the room's anxiety. So how do you prepare? Know your personal limits and your comfort zone. If you're in there and there's a lesion there that's four centimeters and you're like, eh, I could do it, but maybe today isn't the right day, or I just don't know, that would be your comfort zone. Say no, live to see another day, right? Gain some experience with difficult polypectomies. So if you have a day, let's say it's your admin day or if you're a trainee, go with the person who does big polyps, seek them out and ask if you can participate and observe. The more you participate, the more you observe, the better you're gonna be. Even going to something like the ASGE's EMR Star Course is gonna be helpful because it's gonna give you pointers on how to deal with these bigger polypectomies, so lower endoscopic mucosal resection. Be familiar with the equipment. If you're unsure with what the equipment is, a couple of little pearls here, besides practicing and going through with your tech, on every package, there's a schematic. And so looking at the schematic, you will see how big it is or how small it is, the length of it, mechanistically how it works. So check that, that way you don't have to open up a package of let's say a $200 piece of equipment just to see that it opens and closes. You'll be able to get that from the engineering schematic on the box. And then always be prepared for the unexpected, and that's where really good informed consent comes into play. Finally, communicate with your team. I always like to say that there is no I in colonoscopy. So colonoscopy is a team sport. You're all working together to improve the care of the patient and get the job done, and so communication is key. Set the tone. And so a couple words of wisdom here. Just because you can, doesn't mean that you should. And then the second thing is, the lesser the indication, the greater the complication. And with that, I'm going to thank you all again for your time. I thank the ASG for this opportunity, and I'll open the floor for any questions. Thank you very much, everybody. Thank you, Dr. Obstein. Great presentation and overview. We do have a few questions here, and I'll start at the top of the list, is do you inject some substance on your pre-clippings? It really, I think that question, when you say pre-clipping, I assume that it's for a gastrointestinal bleed or a bleeding post-polypectomy. I think it's really an option that you have. In general, I have not been injecting epinephrine before clipping sort of a vessel. In our institution, we do have the clips that can open and close. So what I'll do is I'll go in right away. I think it's your best shot the sooner you can get down there to sort of help stuff out. And I'll close it on there, see if it actually works to tamponade or compress that vessel. If not, I'll open it back up as I showed in that video there, close it back down. And then when I'm confident that it has gotten successful hemostasis in that position, I will have that clip fired. I do find occasionally if I'm concerned that I just can't see the field, it's a red out. And I just wanna maintain a little bit of temporary ability or clarity to see. I think injecting is good. It's the epinephrine solution that we use with submucosal injection there. What I would encourage you to do though is instead of injecting it right at that site where you think it's bleeding, I would inject it a little bit away. And the reason why I say that is you have to think almost like the vessels, right? Where are they coming from? They're usually coming from the sides into that crater, into that polypectomy site. And so you wanna try to get them as they feed in because something like epinephrine injection works by two mechanisms, right? One, it works by pharmacologic. And then the second, it actually works by tamponade because it's space. And so when you inject that in, you're actually creating space. So physically you're tamponading and chemically you're tamponading. When you do inject and you create that space though, it can deform your polypectomy site, making clipping more challenging. So when you do inject, just be mindful if you're gonna do it where you're injecting so that you make sure you're not sort of altering the polypectomy site to get more durable hemostasis involved like a clip. Again, I do not just put some epi in. If you're gonna use epi, you're gonna need to do something else like clip. If you're gonna clip on a post polypectomy bleed, that's fine. You can do that. You have it and you can see it in real time. Very good. I think this is a good follow-up question here is, what is your go-to lift solution for EMR? All of you is expensive, but saline obviously does not leave the nice blue dye. Any recommendations? Yeah, I think there's a lot of solutions out there and to sort of be company agnostic, the lifting agents or the reverse phase polymers, which are the ones that they go in as a liquid and then when they hit the temperature of the body, they solidify or form a gel are really nice because it's sort of an all in one solution. So if you're fortunate enough to have those at your institution, they are great to use. It's sort of all in one approach. If you don't have that, certainly saline is fine. You're absolutely right. It doesn't last a long time. But if you do your injection right, it can last long enough for you to take that polyp off. Now, you're gonna ask about the blue. I would encourage you, you can always dye it. And so what we'll do is usually if when I was using saline, I'll take that jug of saline there and I'll tell our nurses to put some methylene blue or indigo carmine into that, just so that it hinges that clear water solution to the color of Windex, right? You want it Caribbean blue, like the best blue sea that you could ever imagine once we're all able to go on holiday or vacation again. That's the color that you want that water. And then you'll just use that as your injection. So now you have your blue dye in your saline, all in one to do your lift. And then there's combinations there in that you can use. So some will add like head of starch and a little bit of epinephrine and some blue dye and create their own bag of solution. That's also reasonable. There is evidence that head of starch can maybe increase your lift duration, so it lasts a little bit longer. There is some chance, there's some reports of it causing some scarring or local inflammatory reactions. My honest opinion is find out from your institution what you have and get comfortable using what you have at your institution and continuously see if other options are available. So while it might be prohibitively expensive, let's say now at your institution to get one of these reverse phase polymers that sort of lift and stay lifted because they're a gel. Now, maybe in the future that price will change or there will be a different rate with your institution. But any of the options are fine. It's certainly better than no lift at all in these cases. And you can always dye a clear solution so that it looks like that Caribbean blue and that'll stain that submucosa really nicely for you. Excellent, thank you. Next question is how long does the interloop remain in place post-polypectomy? Does it fall off soon? And if so, what is the incidence of post-bleach? That's a great, great question. It falls off when it wants to is essentially the best answer that I have for you. Hopefully it stays on longer than when you're still there, right? So the worst would be you do everything great, you take your polyp off and all of a sudden that loop just like falls off with you while you're still in there. You're going to know it because it's going to start to bleed. In general, these things will slip off as that tissue sort of almost like the crosses down there and creates its inflammatory response right there. Because essentially what you're doing is you're just putting a tourniquet on there and strangulating it. And so you don't have to go back and get it. It's nylon, it'll fall off, it'll be passed in the stool. Next question is, is there any benefit with the use of biopsy forceps to clean up the margins of a polyp versus APC? Yeah, I think if you still see little areas of residual tissue around the edges, it's very reasonable to use your biopsy forceps to pull off that tissue. Again, you want to try to clear all of that pink tissue that you see there, anything that you think is still there within reason. The technique that I generally tell our trainees and certainly at these conferences with the biopsy forceps is, if you think you can fit the entire tissue specimen within the cup, when you open it up, there are two cups, within one of the cups of those biopsy forceps, then you can use the biopsy forceps. If it's bigger than that, then you should think of another method, like let's say your cold snare, or you can use snare cautery on it, or even an avulsion technique. And that's basically not a hot biopsy forceps, but it's very similar in that you grab the area, it's actually on cut setting, not on cautery, and you pull it as you take the charge into it. So as you put electro cut mode onto that avulsion forceps, and you pull the tissue away. So those are all methods that you can use. But in specific with biopsy forceps, if you think that that little residual tissue would fit nicely in one of those cups, take it with the biopsy forceps. Jumbo biopsy forceps are great. Again, you can look at the size of the different cups there, but jumbo biopsy forceps are generally great. You can take those areas of tissue nicely. And then remember, the second principle then, is to touch up the post polypectomy site margin. So go around the area, put APC down, short first, or use soft tip snare coagulation with just the tiniest bit of the tip of that snare out and going around same way to touch up those margins. Again, it reduces the risk of recurrence of that lesion in the future significantly. Excellent. I think this is a follow-up question to your other one on injections, which is, they're just curious if you use methylene blue injections typically in your practice. What kind of what you do on a day-to-day basis? Yeah, you know, so I'm fortunate enough that our institution, we do have one of the pre-stained, you know, polymer gel lifting agents. So I've been using that more commonly with my endoscopic mucosal resections. Before that, I was making my own solution using methylene blue. And again, I would just take a 500 cc bottle and I would slowly have the nurse drip in one drop at a time, the methylene blue, and then shake it up and see what color it was. And when I was happy with the color, again, when it looked like a bottle of Windex or a Caribbean sea, that would be it, great. And then I'd have them draw that up into solution. Okay, very good. I got a couple more questions here and then that's it that I have is, any documentation pearls that you have learned along the way when you're dealing with adverse events? Yeah, I think, you know, the key thing again is make sure that your informed consent is really well done beforehand. And that whoever's in charge of scanning it into the medical record or putting it into the medical record, make sure that it actually gets there. In the actual operative report, we are all aware that adverse events happen. Despite best intentions, they do happen. So the best thing to do is document exactly what you did and what you thought and what you saw. So if you have a bleeding, you know, there's always a section there, estimated blood loss. Estimate it and put down, you know, hemostasis achieved by placement of two clips. Watch for an additional 60 seconds. There was no bleeding after that. Bleeding was successfully managed, done. In cases of, let's say, perforation, you know, document what you saw. Took off a polypectomy. This is the technique that I used. Unfortunately, you know, saw, you know, peritoneum or perforation there. Patient was stable. I decided to manage it like this. Patient will be admitted. You will never go wrong for being fully transparent and honest in your operative report. And so, in fact, it's really helpful for a variety of reasons. One is just for quality and for training and teaching so that your colleagues and everybody can learn from that, including you, after an event. Two, we all know that these happen. And so getting comfortable with managing them is gonna be to your advantage and to the advantage of your partners and the staff around there. And then three, you know, if the patient or their family ever wonder what went on, it's all fully transparent in there. My sound opinion is that, you know, patients own their own medical records. This is my opinion. So they have the right to see their medical record. And so this is part of it. You were fully transparent with consent process, understanding the risks and benefits, and you did your best to manage it, as I said, like a champion. And so there's no reason to not document this down. And feel free. You can put it in the findings of the report, in your polypectomy section, or most of the reports also include a complications or adverse events section that is perfectly appropriate to put in there as well. Excellent, thank you. The last question I have is, what's your general approach with the distance between the clips you would use to close off the polypectomy site? I'm going to try to interpret that question. I think you asked the distance, meaning how big of a site do I look at and close? Or is it like, how far apart do I place the clips? I know we don't have an interchange. So I'm going to try to answer both of them as best as I can. So I don't necessarily close every single large polypectomy site that I do. I think it's really on a case by case basis. So, let's say I've done an EMR and I've taken out a five centimeter lesion. If the patient's not on blood thinners, is reliable with their family, lives close by to our medical center, things went great, there was no bleeding with it, sort of perfect technique. I don't close those areas there. For other items, let's say I took off a four centimeter lesion or a three centimeter lesion, it's an elderly patient. There was no bleeding during the procedure, but they got to go back on their Warfarin and they might live a little bit far away. I'm going to clip that close. Because the odds of that bleeding in the future go up. As we know, they have age, they can't handle a bleed that well, they live a far distance away and they go on blood thinners. So again, it's a case by case basis. Just because it's a large polypectomy site, big, doesn't mean that you have to clip close it. Use your best judgment and assess both the patient and how the defect or how that area looked and how the case went. I think the second question, I'll interpret it the other way is, how far apart do you place clips? You don't have to put one right on top of each other and burn through 40 clips to make it look real nice and put them all in an area. Those make great videos, but they're not really good as far as economics of the thing and time and your ability to handle patients. Remember, these patients are generally under sedation or anesthesia. So you have to keep in the back of your head, the longer you're in there, the more anesthesia or sedation they're getting, which means that the adverse event from anesthesia and the risk there of either anesthesia adverse events or even barotrauma go up significantly. So you don't want to be sitting in there all day either, putting these clips so it looks really nice so that you can shoot a picture of it or take a video. So I would say, look at that area, clip it and then go down a little bit, clip it again, if that's what you're gonna do. They don't have to be right on top of each other. They can be a little bit away, let's say, I don't know, a centimeter or so away as you go down to zip or close it. And you'll see when you bring the tissue together, even though they might be like a centimeter away, it's gonna bring that tissue opposition really, really well there. That's for bleeding. Perforation, it's a different story. Perforation, you want to make sure that your clip nice and tight, close there. So there, it's sort of like clip them, make it look nice, really get it set, put together well. The other technique with clipping that I would encourage you to do are these areas that look like they're sort of nice and round. You're like, how am I ever gonna get a clip over there? My clip only goes out this far. I can't make it three centimeters and pull that in. The technique that you can use is you can actually clip normal tissue furthest away from your scopes or farther away, right? Remember, if you clip closest to you first, that clip is gonna be dangling in front of you. You're not gonna be able to see behind it. You're gonna have a challenge putting additional clips on. So go furthest away from you and put it normal to normal together. What that'll do is that'll bring normal mucosa together almost like start a ridge. And you'll see that round area there then that you're doing your polyp will slowly start to form into a diamond and then slowly come into a straight line simply by starting to clip the normal tissue together proximal to where your polypectomy site is. And then as you do that, you'll follow the line all the way down. So that's how you can get a larger area to close despite your clip not being able to open that far. Excellent. That was our final question. And thank you, Dr. Oberstein for a great presentation tonight. And thank you for everyone who participated in tonight's webinar. Finally, don't forget that you do have access to the recording of this webinar and can engage your peers by accessing the archive on gilead.learn.psge.org. We look forward to next week's webinar. If you're interested, it'll be on Thursday, February 18th at 7 p.m. where we will be having an interview with Dr. Klaus Mergener and Dr. Kramer on talking about the COVID vaccines, the current state and progress forward. We look forward to seeing you there. And this concludes our presentation for this evening. We hope tonight's information is useful to you and to your practice. With that, good night and good evening. Good night, everybody. Thank you.

ASGE webinar

Dr. Keith Obstein

adverse events

polypectomy

visualizing lesion

enhanced imaging techniques

bleeding

pain

perforation

incomplete resection