One of the things that we've noticed over the years giving these courses is there's a wide range of people doing EMR and some of it is kind of like if you're going to jump off a diving board at 10 feet tall versus one feet like or 10 meters, you feel different comfort level, right? So each of you is going to have different scenarios like myself, since COVID, I have like nine brand new nurses and some of them have never seen a snare before. So, you know, when I'm doing like a huge EMR, I have to like really change how my approaches, right? So one of the things that as you're going to progress, if you're doing more and more EMR and you start getting questions of how do I introduce this? How do I introduce that? And so I want to walk you through a little bit of the ways you can look at your individual skills and say, when I leave this course going forward, how do I change what I'm doing rather than staying still? And so, you know, if you're not already doing a lot of EMR, you know, or you're doing some, you might have a different concept than we might have of what easy versus difficult is. And also, how do you know on an individual level you're doing well enough, right? And use the podium now. So one of the things that's interesting is if you look at studies of people undergoing training and you ask them to assess themselves, most people in these studies will say that they're above average. So that's not good. Like, if you ask me, do I think I'm funny? Then I'll probably say I'm above average. My wife will say, no, you're not. Right. So so, you know, in this course today, I want to try and give you ways you can objectively triage things. OK, so so if we say just look at polypectomy and we say, what's the rate of recurrence after polypectomy? There are studies in a building across the street from me where they took regular cold snare and they had people use it and they started EMR in those sites and they were seeing there was a lot of recurrence in basic technique. Right. And so when we look and say, OK, well, let's look at all the studies out there, they all show we don't have perfect results with polypectomy. And so that extends that if polypectomy extends to EMR or other things or even more challenging things like ESD, our rates of recurrence are going to be fairly high. So if we look at the best centers publishing, they still have recurrence rates of six percent after EMR. Right. So when we say, OK, well, what was it? Is it just the polyp size? Is the type of polyp? And it's it's a number of things. Right. We know that the endoscopist, which is why we're here today, there's the polyp itself and there's the technical things that we do. And that's why we have a course like this. OK, so we say, well, what are the biggest centers? What are how low are they getting? And when we compare all the different types that, you know, there's an explosion of data right now. Right. It's really important to look that conventional EMR has really high recurrence. So you have to start adding in things like soft tip, snare, coag and these other things. You can get to lower rates, but each of you will have different skill levels and different things you're good at. So how do we how do we unwrap this? And then we look in some studies where people started EMR and say, well, I can't. Why didn't it work when the group started extending their EMRs and just taking bigger margins? Why didn't that work? And they say, well, maybe there's stuff in the base as well. So we don't really know 100 percent what's the perfect technique to get zero recurrence at this point. All right. So when we have a course now, we want you to optimize your individual skills, but keep watching the literature to see so that as these advances are exploding, you can understand why would I use underwater one time and cold snare another? Or why would I do a cap or other things? Right. That's the only way to look at it. So we think that with zero recurrence, you have to do really good wide margin, ablate things and potentially even ablate the base going forward. But we don't know this for a fact. So we'd say, OK, but there's people doing stuff like this where you're doing a completely circumferential lesion, 10 centimeters long. Right. So it's possible. Right. Technically, a lot of things are possible now. So how do you get from where you are now to getting to here? Right. That's what I want to talk about now. So then we say, well, we have all these different videos and talks and lectures and videos coming out and studies. And there is one after another. What do we do? Right. So if you're individually, you sitting there looking at when I make do I make a choice? Do I do EMR? Do I do the hot cold? Do I inject? Do I underwater right now with a case in front of me? And you have to look and say, well, these are all the questions that come to my mind. Or the people here about, well, can I remove this on block? Is there a cancer risk to it? What's my technical success? If I'm having someone driving from eight hours away to come and see me, are they going to want to come back the next time? Are they local? Am I sure that I got all of this? Is there a recurrence showing up every time someone comes back in certain cases that I'm always getting recurrence or I'm not getting recurrence in my follow ups? How many serious adverse events like people are being hospitalized with bleeding? Is it because they have other recurrences that are really easy or I'm having to refer people because it gets so fibrose I can't deal with it after. Right. Is cancer happening in long term follow up? You're probably not going to know about that. But so at the bottom, if you're at that person, are they are you learning EMR, which is a very different group of people to someone who has been doing it for a little while to someone who is an expert at a referral center. So you can start to see that you can triage a little bit based on what you know. And so when you look and say, well, what are all the things that we know like deal with EMR recurrence and influence it? You can have a whole list of things, right? Your snare types, your needle length, the type of solution you're using, how good you are at tip control, how well you can resolve your loop and how efficient you are in your movements, your decision making. And then you start to get into the technique itself and all the different elements. Right. So we're going to try and walk through these things and then practice them in person. So you have a better sense of what your strengths are so you can use those strengths and not necessarily feel that you have to do all the tools in the toolbox. So what I've tried to show you then is you can break down polypectomy into your planning, into the intraprocedural aspect, into the post follow up. And then you can match your skills to the details of the polyp that's in front of you and to that patient. And consider that we're at the stage now where we have so much choice and we have an idea of what the data linked to a lot of these things is. We can start having an individualized polyp specific strategy going forward. And the key thing, I think, is right now the world has changed. Right. Pay a lot of attention to your team, because if you can train your assistants well, then things like snare closure, which I took for granted a lot in the past, an injection speed and the communication, those are elements we want you to do in the lab here. And make sure like how are you how are you how do you have a flow of your patients and productivity, timing of breaks over time, these sort of issues. This is more relevant than ever. And so when it comes to like what are the settings, you can ask all of us and we might all have different settings. But one thing that's uniform is that if you're closing your snare really tightly before application of current, that has the biggest influence on how much energy is delivered in the settings themselves. And so when you're using things like if you want to optimize tip control, a lot of the most difficult cases are at flexors. And so or so if you're intubating and you're resolving loops as you go and you stabilize your scope, using things like an imager can help you identify where polyps are and make your control a lot better in that sort of situation. Then we move into the polyps themselves. Right. And so when you come up to a polyp and I had a fellow the other day that when we were doing a case, he's like, oh, I want to do this case. It looks really easy. I was like, actually, no, this is going to be really hard. And it's going to take us more than hours. Like, what are you talking about? I'm like, well, it's non-granular and there's scar next to it. Right. And so when you look at it, you should already have some sort of idea just by the diagnosis of the polyp, which things are red flags and which things are routine. Right. So the polyp location is a big one. And for some people, the biggest, because things like appendiceal orifice and aeolicicle valve have high failure rates. Right. And no matter how good you are and then things like anal rectal junction and on the edge of a diverticulum or out of flexure, there are things you can't change. They're going to be hard no matter what. So when we look at like specific locations, you can't use the same techniques that you always use. You have to adjust. And so things we're going to see videos and appendiceal orifice cases, but there's more submucosal fibrosis and it can be hard to visualize parts of the polyp. You have to use smaller snares usually. And if you inject or if you do underwater, it's a different technique. And you have to have. And so you look at this group who did a large number of these. They made this recommendation that if more than 50 percent of the orifice is involved or you can't see the proximal aspect, then you should send for surgery. Right. Versus. And so here are some images from their series of cases that if you look at these pictures, how many of you would feel comfortable doing any of these? This is a referral center. Look at these said, no, I'm not touching this. This is going to the OR. Right. So you have to get a sense of triaging as you're doing the exam. So when you start doing cases, the anal rectal junction, you have a different sensory innovation. You have different venal lymphatic drainage goes directly into systemic circulation. So in those cases, you might want to do prophylactic antibiotics to avoid systemic bacteremia. And so this is an article here that talks about what all their techniques recommend in this. So when you look at anal rectal junction and rectal cases, there is a lot of literature about the colon versus the rectum being different. Right. So if you start reading about this and you wonder why is it the case that this anatomy is the big reason. And so we'll talk later in the pathology section about this a bit more. But it definitely has implications for when you're doing EMR, when you're doing ESD, when you're doing operations and when people are using chemotherapy for early cancers. Right. So because of this, this anatomical factor. So when we look at the polyp size, the big cutoffs are two and four centimeters because over two centimeters, we're no longer doing on block. Right. We're doing piecemeal usually at this point. But when you're getting over four centimeters, a lot of studies say this is the cutoff where you start getting very high rates of polyp recurrence without extra effort and extra measures. And if you have a lot of folds involved or you start getting a circumference involved, like we showed you before, the risk is different and there's different issues come up. So, for instance, with that circumferential case is a very high rate of strictures afterwards. And you end up having to balloon dilate them. And I don't know how many people have regularly balloon dilated in the colon or have like protocols in place to deal with this. But that is something that's been reported as well. So this is what the group was in Australia was saying that this is predictable. And so basically, if the polyp was more than four centimeters in size, if you had intraprocedural bleeding or high grade dysplasia, you had any of those points, then you have a really high recurrence rate. And if you had none of them, you had a really low recurrence rate. So you could predict based on polyp features what was the likelihood the polyp would be still there when you came back at the follow up. And so you can also know that when you're doing and we're going to see a lot of discussion today about non-granular versus granular polyps, that they have different cancer rates. We'll talk about that more detail. But there is a technical difficulty inherent to these polyp types. So very bulky polyps, it can be hard to remove just from the sheer size of them and the way the polyps fall in your face and block your screen versus something non-granular, which is going to be very different. And so when you get these, you have to look and say, OK, well, should I remove this? Is it a scar or an ulcerated polyp? And if it is suspected cancer, then that's where you do tunneling biopsies, tattoos, surgical referral. But if you have these subtypes, then you start having this big debate that we're going to explore about, well, when is it suited for EMR or when do I need to do specialty techniques? And people have tried to study, well, why is the polyp on the left so difficult to remove, the non-granular? And they were saying that potentially, actually, your injection doesn't stay in the same place in the same way because of different protrusions in the muscular smucosa and there's more vascularity. And they've actually shown that genetically there's differences in KRAS and other mutations that actually mean that these are biologically different polyps. So that's that does it's not just our impression that they're technically difficult. It's there's biological differences between these polyps. So when you're how do you know if you're doing well enough? Right. You're supposed to be using your image diagnosis. So Neil is going to give you a talk right after this about how to actually do this and run through practically showing you polyps. But if you're missing depressed lesions, right, and if you're missing, you're getting specimens back, they're showing visible cancer or you're actually resecting cancers and not realizing like subtle things, I don't mean overt cancers, then there will be more bleeding, more perforation, more residual polyp because you have submucosal invasion. And so then not understanding the subtleties and how you arrange your planning during the exam when it's granular or non-granular and how to adapt for these things. So the strategy element is very important in EMR. And so then you have to consider, are you setting up enough time? Are you in a setting where you can do that and trying to understand which cases are better for you? And look like I personally book like an easy case, usually after an EMR, just to give a mental reset for the team, because all of us right now, if we're saying we're really like behind the eight ball trying to finish on time and stuff like that, it's you don't want five straight EMRs that are complicated. Right. You need a mental break and the nurse needs to clean the room and do other things. Right. So you have to plan how what works for you in your scenario. So then, you know, when you're doing when we look and say in all the star EMR courses, when people have done really badly, it usually starts with injection technique. If you're not doing good injection. And sometimes that's because, like I said, you might have a new assistant. You're not used to working together. So we've always advised to like pre inject before the needle pierces the wall. And if that doesn't work to do a needle tenting upwards. But we've seen people over inject. And then you have a hard time influencing the snare laying. And we've also seen people under inject. And when you under inject, that's the hardest one to diagnose when you're watching a student or a learner, because you're not sure, is it non lifting or is it just under lifting? Right. And so that's where, you know, we would encourage you, if you're not routinely lifting all the time to practice lifting and work on that, because the biggest gains come from this section. And so you should be able to while you're doing it, anticipate a suboptimal polypectomy. So if you look at this case and go, is this injection good enough? Would you start removing the polyp right now? Or would more injection help or would more injection make it worse? Right. So if you look at this, if you imagined and you visualized removing this, what would it look like afterwards? And so in this case, when there wasn't enough injection in the front and there ended up being a little bit left over when the resident tried to remove it. Right. So if we have this case that I took actually out of the Red Journal is that they showed injection. But if you look at the picture on the right, is it complete? Right. No, it's not. Right. But if you don't know to look for it and you're not used to inject assessing defects, right, which is a skill that is part of EMR is looking at the defect after you're moved and saying, is my cautery, the electrosurgical energy delivery make a big white rim and then I can't tell what's what right? So that's why if you mark pre mark things it makes it easier and it's been shown in studies to be more effective But a lot of people will look at this and not notice it, right? And so if you say, okay, well, is this perfect like or maybe we need to do me a mar Maybe I'm being super picky I should have also bit or it's all done like you have to be able to answer these questions every single time You're doing EMR, right? So if you have this kind of case and you look at this, would you how many people would do nothing here? How many people would refer this to somebody else? How many people would deal with this now? Show of hands, right and how many people would do a follow-up in a few months? Right. So if we say okay what I use cold snare now what I use hot snare What I lift and repeat EMR or what I do cold avulsion hot avulsion thermal ablation I mean, we have a lot of questions. So what do we do? Right? So if we start saying, okay Well, maybe my injection didn't work. Well, or was it the polyp? Right? How do you figure out which one it is? So if you're getting things like this I'll just say that here that red area is Actually still polyp and you have to remove this mechanically till there's none left and then thermally ablated, right? but if you start off and I said injection is usually where a lot of people are making mistakes if you start seeing things like a jet sign or things are non lifting or you're getting intramucosal injections or canyoning then there's Those are things you have to be able to pick up while you're doing inadequate injections and Then you say well if I'm at can I use lifting to kind of tell if something is cancer if my image diagnosis It's not great when they look at studies of the Japanese They've shown that basically if you involve the entire submucosa down to the muscular spropria, then you can't lift But if you have something that's involving the upper third or the second third Then you can lift because there's some tissue left over and so you can lift cancers, right? Early cancers can be lifted. And so they actually said that doing a biopsy or even injecting Affected their ability to assess lifting quality. So historically we've not thought that injecting Really screws up the site but we're all of us are sure that if you biopsy things it does create fibrosis and I've had cases where I've done a big EMR and the only place it came back was where we were the original person had Biopsy the edge thinking it was okay, right? So so as you're doing your cases and you're doing every step of the procedure can be something that you can improve and optimize But and so when you get to these cases Then I would say don't be shy depending on your skill level to refer these because they have as we've shown Unique characteristics that are different from the usual lift and cut Type snare that we're doing and when we look at say sessile serrated polyps, that's one thing I've I've probably seen about 2,000 people do EMR through the various courses over the year and the one thing I've seen the most is people not as underestimating the size of polyps and When you have sessile serrated ones are indistinct if you're not used to doing this and maybe you're not lifting you're not necessarily appreciating how flat and how subtle some of these lesions can be and You know So that really has a big impact on your triage if you're expecting a small lesion and it turns out it's semi circumferential, right? So so the point I'm trying to get at is that when you're trying to improve your individual skill you should be measuring recurrence rates and you should be like doing standard technique really well and Doing at the moment thermal ablation of the edges and then looking at your toolbox and say well when I have Specific cases where my standard stuff doesn't work there's all these new options out right and the it's a moving target right now and They're not always compared head-to-head and apples to apples So you watch these studies and we'll we'll go through them in a little more detail But there's a lot of different options that people in this room are already doing so you can we can go into more opinions from them of what helps them so I Hope that gives you a sense of the overview of you know What we're gonna try and work on this weekend and try and think of that What we're seeing is that when people are doing? Doing regular EMR. There's a lot of variability And so then we add in all the studies where we can add extra tools and you're like well if I'm if I'm a beginner What do I do? How do I do what this you know, someone's doing 10 cent in a circumvential? How do I do that right away? Do I even do that? Right? So the beginning of the discussion So now we'll come over to we'll stop if you have any questions first In this case, there's no Silly questions. So like just ask everyone. Oh, yeah, I may test you with that. No, sir questioning when it comes to appendiceal orifice Twofold thing Prior appendectomy or not How does that influence you and then secondly? When I've referred to surgeon before when they had a prior appendectomy and I maybe didn't realize that during their screening The surgeon wanted them back for a tattoo of the area because they thought that would help. So when you would do approach polyps that are in Invading into the appendiceal orifice and you know, you can't resect you do anything in preparation to help the surgeon tattoo or do anything specific? Or in the fact of a prior appendectomy or not. Does that how does that influence you? So from a tattoo point of view I would say that My feeling on that has evolved over the years And that we've seen that in our different centers. Everyone has a bit of a different opinion, right? So what I used to tattoo all the EMRs now I almost tattoo none of them and the part of the reason is because I've started to get a lot of polyposis patients that I have five or six Tattoos needed and then surgeon goes well which tattoo matches the polyp now, right? so I and I have a lot of referring doctors who've been very happy to tattoo and then the polyp has been Tattooed underneath it and now my job got a lot harder because there's fibrosis So in general what I'm doing is asking my local surgeon Tell me when you want a tattoo and we'll do it then right and so for appendiceal Haven't been had that as a request. Does anyone here had that as a request? You've had that Many times we talked to them no matter what if they're going in there They want to see a tattoo even if it's close to the IC valve and you say well, it's right on that's your tattoo and Sometimes we have a long discussion and we do it and sometimes we don't yeah, so I wouldn't say it's particular because it's appendiceal It's more Surgeon preference is what we what we see that wouldn't say there's any reported literature says you have to do that I guess what I was getting at was this patient had a prior appendectomy Yeah And he said it would be it was more difficult for him to Identify the location of polyp then after the fact so I've got to bring the patient back Yeah, to mark it at the appendiceal orifice for the surgeon So I'm saying if they had a prior appendectomy that hasn't in our centers our surgeons haven't asked for that Okay, that's what I mean I said there's a lot like it's not a son in a guideline or anywhere and a reported thing and that Appendectomy changes your technique and I would say there's enough features Things like mucoceals and other things that you know, a lot of times your ability to diagnose There's stuff that's hidden and with appendiceal lesions Watch there'll be some videos in our on the last day where we'll watch doing that so we can talk about it more Because it's a big topic other questions Is there any literature about how Clipping may Influence recurrence rate. I feel like I when you take out these large polyps, especially on the right side There's this impulse to clip that is balanced by what would if they have a recurrence? Is there a risk of burying neoplasia? I'm just wondering if there is any literature about clipping and recurrence rates or clipping and very neoplasia rates That's a great question. I Hear where you're coming from I don't think that anyone's done any literature on that front showing that clips are a contraindication. I would say You guys all feel comfortable pulling clips off, right? So we've all felt comfortable pulling clips off that are there and then treating I would say that from let's say a learner point Of view and teaching people I would say the the biggest hardest thing is trying to diagnose. What's the tissue? That's artifactual created by the clip being there and so You know and when Neil will show you polypectomies, that's standard stuff. And then once you have a post EMR scar Differentiating what's clip artifact versus recurrence is quite difficult So you have to be used to using white light and NBI and magnification But I don't think there's been any thing to suggest that it would be contraindicated or if you've seen any buried neoplasia After these large polyps, no No, I'm not sure that there's a specific study that's been designed to look at that to be honest like it's hard to look for It's like yeah Yeah, I mean that's why I was showing you those studies where people have tried to figure out Why are things recurring right if you look at the the group in Australia that did wide margins and then they did a PC And then they did soft a quag you ask them. Why do you think it's happening? They said we have no idea, right? We're just trying these different things and getting better results And then that French group that looked and they start finding stuff in the base all the articles before that We're saying it's lateral margins lateral margins lateral margins all of a sudden. They're like no we're finding things where Microscopically, it looks normal with massive magnification and all the techniques we have and you remove it and there's still stuff there So that makes you wonder and say, okay. Well, maybe we've been thinking about this wrong. So it's not even macroscopic Routinely burn the base that may be I've started doing that more but I'm not sure that's evidence-based and I wouldn't say that you Should take that home as a recommendation from us Yeah Anyone else have a comment on that or I mean I'll throw out if there's a case of a buried Colon neoplasia after EMR that would at least to my knowledge I think the first case report that we've actually proven that so if you find one Please submit it to a medical journal because that that would be the the first report of that What's the average time that a clip will stay on I mean you talked about pulling them off I haven't really pulled one off and could you tell it talk about if you imagine let's say if I'm a clip If let's say the the grabbing portion here is the only part grabbing then it could be really short I've had clips that I put in that three years ago are still there, right? So I think it depends how much you how much you grabbed and how much it's and then the clip Manufacturer how much tensile strength like if you have the quick clips from 20 years ago versus one of the newer clips you might have Different retention as well. Do you anyone seen that? Yeah Yeah, so you can't there's no rhyme or reason you have a specific technique to pull clips off I feel like it's not so easy when you've done cautery that they often granulate in Really hard. I mean, I you just I put I don't put a cold snare around it I put a like a fixed snare around it and I pull and just Where do you grab it? You grab the tissue to the wall as possible to myself But you guys The next thing is we'll have some opportunities tomorrow today actually to practice on the big lab of pulling clips or Resetting around clips. So like these models are really tough They're not like the esophagus that like it's not made of saran wrap So you'll be able to really just do things you wouldn't feel comfortable doing any human being All right, so I will come back to you Just a follow-up on the appendix here. Yeah orifice polyps. So before sending to the surgeon should we biopsy? I Would say that from There's no harm in biopsying in that sense Right because it's not like you're gonna try another resection unless they're gonna send it to somebody else kind of issue But I would say that you know If they feel that they're willing to operate without it Right because we don't feel like a none of us feel that we should be getting biopsies I think optical diagnosis is sufficient for all the EMRs, right? So I still have referring doctor saying well the biopsy showed it was fine I'm like it that doesn't change what I'm gonna do if the biopsy comes back you know if a polyp is in front of us and then we still do an optical diagnosis and Look at the look for pit pattern type 5 or depression or these different things And if we see that on our results that might influence what we're gonna do and that's we're gonna talk about When do I do EMR ESD full thickness these sort of things it's it starts with the image diagnosis So I'd say if you're doing image diagnosis the appendix they'll pull up and you feel very comfortable It's benign and I don't think there's any help to doing a biopsy I'm just curious how often You will attempt one of these on like the initial colonoscopy versus how often do you stop and say we're gonna bring you back? Because I feel like oftentimes I'll see something that looks so I can handle this in the next 20 minutes And an hour and a half later you're struggling and I would have wished that I just said We need to schedule you for a longer repeat So I'm just curious if you haven't yeah and I think that's where the triage and the flow part is there's a lot of It depends where you work and what you feel like and if you're rested that day or if you're flying to Chicago right after I've I've I've said to my booking people I don't want EMR is being at the end of the day because no one's around if something goes wrong and it takes way longer to get People to the emergency room and other things if that's needed right the one in a whenever time So I don't I don't think there's a single answer. That's the same for us, but we'll go ahead and you can comment It's a great question. And I think the thing that That I think about is did I do a good enough informed consent to to cover myself and if there was a complication that happened and And sometimes, you know on these kind of screening exams, you know, we we talk about it's about like a less than 1% chance of this this and this and and then if you look at the the literature and and the lawyers definitely look at the literature the their risk of bleeding and perforation with Endoscopic mucosal resection of polyps greater than like 20 millimeters is is actually higher than 1% You can find a lot of papers that would that would cite that so So I think you know for for me and my fellows even on a screening exam I would consent for endoscopic mucosal resection and I do a little bit more of a Detailed more thorough consent with all of those patients just so I feel like you know I Am the patient are on the same page if I got into that scenario The more the more you get used to it the more you'll do like you're saying where you'll say well I also do large polyps and I find one I might do it today Depending on if I think it's too complicated. We might have to bring you back. So that's one of the nuances I'd say as we've got more senior we started adding in senior

endoscopic mucosal resection

individualized strategies

polyp assessment

injection techniques

lifting

difficult cases triaging

EMR tools and methods