So, our first presentation is going to be on just kind of an overview of safety issues having to do with colonoscopy and also medical legal risk in colonoscopy and I think that this is kind of a worthwhile thing to review because it sort of gets at issues that are fundamental that we all need to be on the same page about, I sort of think from from reviewing a lot of malpractice cases, having to do with with colonoscopy that there are some basics about the reduction of medical legal risk that are really fundamental to safe colonoscopy and if you know about those things and if you're keeping them in mind as you're performing colonoscopy as you're doing the consent process. It also leads to good basic colonoscopy. So we're going to start off with this and include some elements about safety because safety is so fundamental to being a good colonoscopist. Safety and insertion avoiding perforation and splenic injury, safety in resection although we're going to come back to that multiple times during the day, minimizing the risk of post colonoscopy cancers and lawsuits over missed cancer, minimizing delayed hemorrhage being smart about dilation avoiding wrong site surgery, the correct management of malignant polyps from time to time during the day I think we'll talk somewhat about vocabulary and make sure that we're all on the same page about the vocabulary of colorectal neoplasia and what polyp really is and how you assess whether or not the patient needs adjuvant surgical resection, and then the basics of, you know, staying out of trouble with regard to screening and surveillance intervals, the informed consent process. So those are the basics that should be in the informed consent process, I think that we should all get informed consent ourselves not rely on others to do it, I rely on the gastroenterology fellow to do it if they're with if they're with me but otherwise I don't have a nurse to do it otherwise do it myself perforation missed lesion delayed hemorrhage these of course are the basics splenic injury, I think you have to decide whether you're going to include splenic injury, I have had eight splenic injuries in the course of my career and about only two of those occurred from insertions that I did myself, neither one of them are required surgery and I will tell you I don't get consent for splenic injury, six of them occurred during fellow insertions and one of those required surgery, and I do ask my fellows to get consent for splenic injury so I don't know that it's mandated but I see more and more people doing it and I think it's, it's, it's probably wise, and then if you're giving sedation yourself of course drug reaction aspiration, it's really important if you're giving sedation to include aspiration we have more trouble with aspiration than we do probably any other element of complications and colonoscopy. Safety during insertion, two keys are don't push against fixed resistance and use water and tight angulated sigmoid so I think this is probably the most reliable safety rule in colonoscopy, when you are inserting the colonoscope, and you feel that the colon is not giving way anymore you've run up against a wall, you've got to stop. You may be able to overcome that by straightening the instrument and trying again, or by switching to a more flexible scope because sometimes when there is fixed resistance, then a more flexible scope will go around it, and you'll feel the scope still sliding. Now a lot of times people say fixed resistance and what they mean is they just put a such a big loop in the scope that you can't push anymore. True fixed resistance from adhesive disease around the sigmoid colon I think is a very rare finding usually associated with a lot of pelvic surgery, not just your, not just a hysterectomy, but a lot of pelvic surgery and often radiation. So I think true fixed resistance is rare but the bottom line is if you don't feel the colon giving away, you've got to stop and I think probably you can go through a career and never break open a normal colon. If you follow that rule, completely systematically never, never, you know, push, never get frustrated and keep pushing, because you're stuck and of course we're trying to avoid rupture perforations that are usually in the rectal sigmoid or the sigmoid, I've seen a medical legal cases up in the more proximal colon, but they're usually distal they're usually very large, and they are probably the most challenging perforations to close endoscopically. The second rule is to avoid barotrauma by every time you enter a complex sigmoid colon, you convert to water you stop insufflating gas, and you convert to water so on the left we have the normal situation a normal sigmoid, we're pumping in gas, this could be CO2 you can get barotrauma with CO2, and this gas in a normal sigmoid can escape back around the scope and get out of the anus but if you're in a very tight angulated sigmoid, then the scope can occlude the lumen so the gas can't escape backwards. If the ileocecal valve is competent to gas it doesn't let gas, come back into the small bowel, then very quickly you get this closed system, and you get distention and cirrhosis tears, and then perforation, and these are the worst perforations that you see in clinical practice, oftentimes, the bowel is dirty, because the patient has a bad sigmoid and they have a hard time passing stool through that sigmoid so you're kind of the doctors working through this angulated sigmoid and oftentimes the prep is not good. So when the perforation occurs there's rapid contamination, but also the air pressure makes the patient sick faster they get septic faster, and they can develop compartment syndromes in the abdomen and rarely if gas dissects into the chest. So, things can deteriorate very quickly. The standard of medical care in these cases requires that you be able to make the diagnosis at the bedside without any any radiographic confirmation and do a needle decompression, and that's going to reverse any severe, you know cardiovascular effects that are and that could under rare circumstances including, you know, a decompression of the chest. So the trick to this the way to avoid this, I've had one of these in my career and it was with co two, and a fellow insertion and we and we did a decompression at the bedside. So it's very very rare, but it's very bad. When it occurs. And the key is to prevent it by recognizing the situation in which it occurs, it only occurs in patients with bad sigmoid colon so when you enter a really complex sigmoid colon convert to water, because water won't have this effect. Next thing in safety is avoiding splenic injury I mentioned that I've had eight of these in my career, all eight of them were in women, the main established risk factor for splenic injury is female gender of the patient, and I don't think we know why this is, I think average, you know, can be a little bit more difficult in women but you have to all the time during colonoscopy, be conscious of the fact that the spleen and the colon are connected, and the spleen can bend but it can only bend so far. If you can pull or twist on these connections hard enough, you can get a crack in the spleen, and that it can start bleeding if that bleeding occurs directly into the peritoneal cavity, you know you can get all the consequences of that if it occurs in the enema of the spleen, even a small amount of bleeding can result in a large hematoma that eventually can literally blow the capsule apart and create, you know, a catastrophe for the patient so we don't have a perfectly formed rule to avoid this rule that I follow is when the scope tip is up in the proximal colon, you're always thinking of that relationship between the spleen and the colon. And when you are talking the instrument in particular, or when you're unwinding loops, you do it gently you don't want sudden forceful movements on those connections. In order to avoid this. Safety in resection. I think part of the issue that comes up about safety in resection has to do with what you are personally prepared to fix and what you have available to use in your, in your unit. And so hopefully you've got hemostatic clips no matter where you practice, I practice in one unit that's not at the hospital, where we don't have over the scope clips or any form of suturing, and you know we talked about, we want these around for the rare cases in which we need to close a perforation, but you know for routine outpatient colonoscopy, the risk is so low that the equipment becomes outdated when you buy it, and then the leadership doesn't want to buy the buy the equipment so I guess if we forget a perforation like that. Um, you know, we're going to have to just sit there with the scope until we're ready to move the patient by ambulance to the hospital and suck everything out that might go out the hole, but I do think that the more aggressive you are with with procedures in general hopefully you also have the equipment and you feel comfortable using the equipment, because we're seeing repeated publications now where instead of most endoscopic perforations requiring surgery most endoscopic perforations are being closed endoscopically and unquestionably this is a better outcome for the patient and results in lower medical legal risk. Part of this has to has to be that we recognize muscle injury, I think it's become very rare now for experts to have a delayed perforation after an endoscopic resection. We may have a perforation during the procedure, or we may have a muscle injury, but because you can recognize it and repair it, it's very late to have a very unusual to have a delayed perforation there's still some delayed post coagulation syndromes but perforation very rare. These are the, this is the Sydney classification for muscle injury type one is you've exposed the muscle, it's not really even an injury. It's not cut it's just exposed type two is you, you, you may have injured it you're not really sure. And so you're going to repair it. This usually is in a situation where you are have a have a lot of scarring and you've taken tissue off residual or recurrent you've cut it off, and now you really can't tell whether you've injured the muscle you kind of are suspicious the layers are tacked together. And so you do something to strengthen the wall to prevent a delayed perf type three is an important one to recognize that this is actually a perforation so here is an example of a type one muscle injury the muscle is white, and one of the advantages of of semi coastal contrast is that that contrast will stain the semi coastal fibers with this blue color, but it doesn't stain the muscle so that's the circular muscle layer right there. It's exposed, but it's not cut, and you can put clips over that if you want to but that is not going to perforate because the muscle has not been injured. So this is a type three muscle injury, and this is a lesion in the proximal colon. We're going to talk a lot about classification this is a granular lateral spreading lesion pretty much run of the mill lesion maybe 25 millimeters. This is the first piece cut off. And now we're going to re inject and cut off some more. Now we often talk about, you know, ways that we can try to limit muscle injury, and one of them is by selecting snares that are not huge. And I suppose someone might be critical of me taking off a piece of tissue there. That's maybe 20 millimeters in size, but right there, what you see are two bands of muscle that does those two white bands right there. That's not muscle. It's not perforated you can't see a hole, and you can actually finish the resection, but you have to recognize that and repair it, or there's a very strong chance it's going to perforate later, and nobody's going to be happy. When this happens, and this is from that same case, you can often see the muscle on the bottom of the specimen that's muscle that ought to still be attached to the patient and instead it's attached to the specimen it appears as a white ring people call that the Here's another example of this now this is one and we'll come, we're going to talk about this some today, where you know things that that we do to pile up sometimes before we resect them may increase the risk. And you can see how dark the semi coastal staining is in this case that's tattoo that's under this lesion. I don't know where the tattoo had anything to do with the fact that I cut the muscle here. But we do like to keep tattoo out from under lesions if we're going to mark them for a for your use later, but you can see this is a muscle band you can't see the muscle band on the other side. And this is one of these appearances where you've got depth to this situation here. And we're going to clip close these and, and these defects are typically quite small they're just a few millimeters in size, and we've put the clips here very close over this defect and then we've gone with the scope over the proximal side the sequel side of the clips and bent them back to make sure that we've got a nice tight closure, I have never seen a closure of a type three muscle injury fail. And here you can see the specimen. In this case you can see the stain on the semi coastal from the, from the ink, and that white circle that's muscle that's on the specimen, it ought to still be in the patient, but it's not because of a type three muscle injury. So, we have to recognize that now this is type four. We're in the middle this is actually a serrated lesion that I was that I was removing with electrocautery, and this is a small snare, and we're taking this off with endo cut, we're going to talk about current as the day goes on. I'm kind of like losing all enthusiasm for endo cut because I personally think I've had more muscle injuries and perforations with endo cut than I have with force coagulation current, but that's a Frank Cole right it looks like a whole it is a whole. No, you've got you can't pretend that it's not a whole. It's very important to not have anything go out that hole. To the extent that stuff goes out that hole, the patient's going to have a fever going to have pain. And so we want to close that, and usually we'll start at, at one end of it you can see here I'm finishing the resection, and it's okay to do that as long as you're monitoring the patient's abdomen make sure that they're not getting, you know, overly distended before you fix the perforation now we're going to talk later about serrated lesions This was done as part of a randomized trial comparing to cold resection, but I don't resect serrated lesions anymore with with electrocautery. And as long as you're monitoring, you can you know you can wait a little bit before you close this, I'm going to try to move down this video and see the final closure, but you can see we're putting the clips, nice and tight together from medical legal standpoint, this is going to be a much better outcome, because we're avoiding surgery, you're not going to get sued for a patient being admitted overnight to the hospital, I would admit this patient overnight to observe them, but that's a night, nice tight closure. This is a initially what was a type three muscle injury that becomes a type five muscle injury now this is in the transverse colon. And the Australia group has has shown that the two most dangerous sections of the colon for perforation are the seek them, and the transverse colon, and it may be because they're, you know, they're not on their, they're free in the, in the mesentery I don't know, I think the transverse colon is also a common place to miss lesions so you can see I initially grabbed a hold of this lesion, and then, you know, thought it had a little bit too much, and then grabbed some more of it. So, I would say that from a from an avoidance standpoint, there probably is some value in using smaller snares and and we're going to talk about this as the day goes on, I usually again, you know, say 15 to 20 millimeter snares for conventional resection you know we we wrote there, here's the here's the type three muscle injury right there. And in just a second you're going to see that break open and become a type five muscle injury and a lot better that this happens during the procedure, then later when it's when it's a disaster if it occurs on a delayed basis. This was type five because some stuff escaped the patient had had a fever was in the hospital for a couple of days, but again, the closure is nice and tight and patient recovered with just antibiotics and diet restriction. Okay. So, in general principles that we'll talk about today cold resection is safer than hot microprocessor controlled current, I'm just going to talk about this this afternoon. I personally think that we have a one randomized controlled trial and it favors the use of force coagulation I was an endo cut pusher for many years but as a result of this trial. I've never gone back to forced coagulation current, and I think it has less immediate bleeding no difference in delayed bleeding and I think it lowers the risk of perforation. But a key thing from reducing medical legal risk is to recognize muscle injury and repair it. Okay post colonoscopy cancers, these are the factors that determine the outcome now, you know, my approach to post colonoscopy cancer. As an expert because I have I've written about this a couple of times and I have testified, four times now on behalf on behalf of patients in post colonoscopy cancer cases, I've testified quite a few more times. On behalf of physicians, and it's difficult. Sometimes to tell what's going on because of course we generally don't have a videotape. So you can't really say how carefully the colonoscopy was performed how carefully the doctor did all the things that make for a good examination looked behind folds and so on. So what are the factors that that the cases come down to, first of all, the tumor itself is looked at very closely, the size at the time of diagnosis the shape, the amount of time, whether there were factors that suggest you could have more rapid transformation, rapid spread microsatellite instability poor differentiation from a causation standpoint in a medical legal suit, there's always the standard of care that has to be demonstrated by the plaintiff. But there's also the issue of causation, which is basically, did whatever negligence occurred make any difference in the outcome for the patient? And factors that suggest more rapid development of metastases can come into play there. The report itself, the endoscopy report is important. The PrEP documentation, was the PrEP adequate or good or excellent, or had a Boston score of at least two in each segment, some measure of that, hopefully accompanied by photography. The withdrawal time is always gonna be looked at. And if the withdrawal time, a couple of times when I testified against a physician, the total procedure had lasted four minutes or less. And you get something like that, it's just hard to say that you did a careful examination. The general methods, I think in general, and it's relevant to this course today, but if you use hot forceps to take off diminutive polyps, and then want to say that, well, I did a careful examination. Well, it takes away from it a little bit because we've had recommendations for a long time that hot forceps should be abandoned in the removal of diminutive polyps. So how the rest of the report looks, has some bearing on everybody's perception of how up to date the colonoscopist is. Some stuff comes out in deposition and it'll always come out if it's favorable to the physician. And that is, are you measuring the adenoma detection rate? And I think Tommy is going to probably talk about whether or not we are expecting new measures of how well you detect. And then what is it? Because you can look at the evidence in the literature and show that even when there are high adenoma detection rates, if you do enough colonoscopy, it's likely that sooner or later you're going to have an interval cancer. So if you have established a quality program and you're measuring your ADR and your ADR is adequate, it's above the recommended threshold, that goes a long way, I think in the defense. And of course, how the experts, what they say and whether or not they make mistakes in their description of misrates and so on is important. Minimizing delayed hemorrhage. This is not a huge area for malpractice risk in colonoscopy, but I think it can be a problem if we don't follow the rules some. For example, we're going to hear about this. We now have recommendations that we should resect everything less than 10 millimeters. I would say less than or equal to 10 millimeters, including pedunculated lesions. So when you have a complication using hot forceps for a diminutive polyp or using electrocautery for a very small lesion, that can be a problem. In general though, we can all acknowledge delayed hemorrhage is the most common complication we see. And it's usually not, it doesn't have a terrible outcome. The patient may be in the hospital for a little bit. They might require transfusion. They might require a repeat procedure, but very rare for them to require surgery or to have a myocardial infarction or a stroke of some kind because of hypotension. Those are the kinds of cases where this becomes malpractice risk. Closure of large pedunculated defects. We have recommendations to do that. And then these are our recommendations to close large EMR defects if it's feasible. It's not always feasible, but to at least say that we tried 20 millimeters or larger proximal dysplastic flexure removed by electrocautery. Okay, a few basics about dilation that I have come from my own experience with looking at malpractice cases. One is don't dilate asymptomatic strictures without a good reason. You don't always have to dilate, for example, an asymptomatic stricture in Crohn's disease just to see what's on the other side. There are other ways to evaluate the neoterminal ileum in a patient with Crohn's disease. It's important to remember that stricture length is an important predictor of perforation. In Crohn's disease, strictures that are four, five, six centimeters in length have a higher risk of perforation than short strictures. And remember that 15 millimeters is often enough dilation in the colon to relieve symptoms. So don't push it too hard unless you're forced to by symptoms not improving. Wrong site surgery. It's surprising how many lawsuits there are about this. And the approach that I think is important to take is that there's a collaboration between the endoscopist and the surgeon and you share responsibility for it. So on our side, the first thing is we need to place our tattoos accurately. That is, get them in the submucosa. That's where they belong. I see sometimes patients that are referred to me with a hollow and there's a tattoo next to it. And all I can see is a black mark. There's no submucosal bleb. Well, that tattoo was not placed correctly. It went into the peritoneal cavity. And you can stick the needle very easily through the wall and shoot the stuff all over the peritoneal cavity. So you wanna use good technique. We're gonna talk a little bit about that this afternoon. Don't in the report specify a specific segment unless you know it. So if you find a cancer, don't say it's in the descending colon. You should rather say, I may be in the descending or the transverse or the proximal sigmoid and please find the tattoo. The idea is the surgeon must find the tattoo because you don't wanna ever be in the circumstance where the surgeon doesn't see the tattoo and then relies on you being very specific in your report about where the tumor is and takes out a section that doesn't have the tumor in it. Tattoo enough. And especially very large obese men, they'll have a huge amount of fat around their colon. And you wanna have enough of a dense tattoo that the surgeon can easily find it. Make sure the surgeon understands they must find the tattoo in the colon wall. They can't go by where they see some stuff splattered around sort of the left colon. They gotta find that tattoo in the wall. Let them know that if they don't do intraoperative colonoscopy, which is what they should do if they can't find the tattoo, that you or your partners will come to the OR. And then this is a trick, because we see under tattooing and now we see over tattooing. I see people sometimes have four or five tattoos in their colon. And if you've got a lesion in the rectal sigmoid and there are multiple tattoos up in the colon, it's really good to tell the surgeon, hey, there are several tattoos in here. You've gotta find the one that's at 17 or 20 centimeters. So you need to do an intraoperative colonoscopy because there are too many tattoos. So note that in your report. Couple of comments about malignant polyps. So we're gonna talk about cancer, endoscopic predictors of cancer. And we all have to be on the same page that in the colon, cancer means submucosal invasion. That's not necessarily true in the upper GI tract where you can have intramucosal cancer and there's a small risk of lymph no metastasis. That doesn't really happen in the colon. So from the standpoint of a clinician, we don't like this term intramucosal adenocarcinoma. From a pathologist standpoint, that means that dysplastic elements are invading the lamina propria, but the lamina propria is part of the mucosa. In order to have cancer, you have to have dysplastic elements going through the muscularis mucosa, that thin muscle layer that separates the mucosa from the submucosa. If it's only in the mucosa, in the U.S. we like the term high-grade dysplasia because when these dysplastic elements are in the lamina propria, we consider this a benign polyp. If we get it out endoscopically, it's cured. But some people don't get this. And when they see that term intramucosal adenocarcinoma, they start thinking surgery. And that's not necessary for a polyp that's been completely resected. You wanna know the factors that determine a higher risk of lymph node mets. And they're different for pedunculated lesions and non-pedunculated lesions. On the pedunculated side, poor differentiation, lymphovascular invasion, a very close margin, or the specimen is not oriented. So what does that mean, the specimen is not oriented? Usually what it means is the polyp was piecemealed out. And this is why it's important for pedunculated polyps to work very hard, even when they're quite large, to get that snare all the way over the head of the polyp and down onto the stalk. And so that the pathologist can bivalve the polyp down through the head and down through the stalk so that we can tell if the stalk is invaded and whether the margin is involved. If you've got cancer in a pedunculated polyp and you basically had to piecemeal it, then unless you've got the last part of it sent separately to the pathologist, the stalk and the bottom of it, then you're probably better off thinking about surgery. Non-pedunculated lesions, some of the same factors. We can add high-grade tumor budding. This refers to little groups of cells that are breaking away from the main tumor. There's the involved margin. The involved margin probably should be a millimeter in most cases, though we've seen some reports that it only has to be 100 microns, a tenth of a millimeter. I put asterisk by depth of invasion because to measure the depth of invasion, you have to have, most people would say, an on-block resected specimen that has been laid out flat for the pathologist and so they can section it perpendicular to the plane that you cut it in. And depth of invasion into the submucosa of more than a millimeter is referred to as deep submucosal invasion and traditionally has been a reason to think about surgery, but recently that has been questioned. So the most important thing from the standpoint of medical legal risk is to realize that any single adverse prognostic feature, with the exception now of depth of invasion in a non-pedunculated lesion, is a reason to consider recommendation of surgery. But in every patient with a malignant polyp, you have to balance the risk of cancer in the bowel wall or in the lymph nodes against the surgical risk. And more and more, the literature is saying if the surgical risk is high, you should not do surgery even in the presence of these adverse histologic features. So you always have to consider that. I think it's best to write a good note that summarizes your discussion with the patient. And then wrong procedure intervals. And you can look up these intervals. We all know what they are, 10 years for screening, et cetera. You just have to have a very systematic approach to how you make these recommendations, how you review pathology reports. And you need to know the guidelines that the medical legal risk comes if you make a recommendation really that's too long. Although if you make one that's too short and you have a complication, you could be questioned over that. It's really best to follow the recommendations, have a very systematic approach, just like we have to have for follow-up of lab results, radiology, pathology results. So when you diagnose a cancer, I've seen this mistake made multiple times. I think as an endoscopist, the best thing is to assume every bit of responsibility for the care. You wanna make sure you discuss it, document it, send a letter to the patient, order all of the staging. We get the CT scans, we get the MRIs for rectal cancers, and we make sure the patient has all of their appointments and they've been notified about it. So you never know quite what people hear in the recovery room and just take all that responsibility yourself. Okay, that concludes my comments. And I hope that a few things came out there that we would all agree are our basics. And I particularly think it's important that they're using sort of the same terminology because this will come up again as the day goes on. So Doug, sorry to interrupt. Do you wanna take a couple of questions or do you wanna do it later? I mean, we still have a couple of minutes. It's 928, so. Let's go for it. Okay, so one of the questions that the audience had is, can you describe the technique for needle decompression? What type of needle you use? Any specific pointers for them to do this? Yeah, I don't think you need really a special needle for this. There are special needles, the varus needle and so on, but you oftentimes people don't have those available. So really all you need is an angiocath and a syringe. I put some water into the syringe, put some betadine on the abdomen, start the needle in. And once you get through the skin, put a little back tension on the plunger of the syringe. When the needle enters the peritoneal cavity, you'll start to get bubbling and then you can thread the angiocath in. Just leave the angiocath in there then, and you can just, I mean, if you've got a tight pneumoperitoneum, you'll literally hear gas escaping like it's out of a stuck balloon or inner tube. Yeah, I think it's very important to have the saline or water in the syringe to see that bubbling. A lot of times I've seen folks do it without and they don't know. So the bubbling is the important, and when it stops or slows down, that is probably the time that you take the plunger out or the other syringe out, sorry. Very good. Any specific needle use for injection? So for injection, for EMR, does that mean? Yeah. Okay, my personal preference is to use 25 gauge needles rather than 23 gauge needles. And it's because it's just easier to enter the submucosa. When you're using a 23 gauge needle, you have to push a little bit harder. And then once you've pushed hard enough to get through the mucosa, you oftentimes pop through the wall. So I find that I get the submucosa identified a little bit faster. When you are injecting for an EMR, and you may be going to talk about this later, Amit, there's several ways to do it. But even for an EMR, you can use a sort of a PPD approach. In general, if this is the plane of the colon, the more on FOS you are, the more difficult it is to get into the submucosa. The more you're approaching tangentially, the easier it is to find it. And if you do a little bit of a PPD technique where you stick the needle in, and then you kind of lift up on the bevel so you can see the bevel through the mucosa, then you're pretty much always gonna be in the submucosa. That's a great technique. I used to not worry about that. I don't worry about it now too much when I'm using starch, but when you're using some of these commercial fluids, they're pretty expensive. And if you have a 10 ml syringe and your technician, I should say a traditional approach, we would put the needle on the mucosa at the point you want to inject, start the fluid in and then push the needle into the wall. And as the needle goes into the submucosa, it'll inflate the submucosa. And that sometimes works. Sometimes it causes what we call an intramucosal hematoma, especially if there's a lot of scarring around. So I use the PPD technique more and I always use it for tattooing. I always try to get tangential to tattoo, lift up, see the bevel, just squirt a little bit in so you know you've got a bleb and then put in your three quarters of an ml or one ml. But I like a 23 or a 25 better than 23. What about you guys? Do you have preference? I use a 25. Okay. Yeah, I like the small needles too. And sometimes the dullness, like I think what you're describing, getting into the submucosa is the hardest part because it's so tough there getting through. So I feel like there were some needles out there that were a little too dull for that puncture. Yeah, yeah. There's a question on morbidity from holding anticoagulation and antiplatelet agents very procedurally and how commonly they become an endoscopy malpractice lawsuit. I think that the way they become a malpractice lawsuit is when people systematically delay resuming them for some period of time. And so, I mean, I've seen practice, I saw a practice one time and I actually testified for the patient in this case where a patient with atrial fibrillation had a stroke several days after a colonoscopy. And it turned out that the practice was systematically resuming warfarin, this was before there were DOACs, one week after colonoscopy procedures, no matter what had been done. And we'd never had a guideline that said that. I think in the US we still are stopping DOACs and warfarin a lot for colonoscopy. I think one of the tricky things about colonoscopy is that our sets of recommendations say that if you're doing a high risk procedure, that is a polypectomy, a larger polypectomy, you should be off these drugs. If you're doing a low risk procedure, taking a biopsy or removing a polyp with a cold snare is often now being sort of put in that category. The problem is when you're doing colonoscopy, you don't know what you're gonna be doing, right? You've got screening and surveillance patients and you don't know how often you're gonna run into a polyp where you wanna use electrocautery or somebody is gonna have a bigger polyp. And it's, I think, very common and acceptable when the patient doesn't have a lot of cardiovascular risk to stop the DOACs for a day or two, stop the warfarin for three or four days. But almost always we should be resuming these drugs at least by the following day. And when people don't do that systematically, I think that's where the risk comes in. Comments from you guys, it's a great, we don't have it on the agenda today, but everybody's always concerned about how to handle these drugs. I think one of the things is always get the prescribing physician involved. I mean, that's one way, because you don't know these patients. I mean, sometimes I feel very uncomfortable making strong recommendations because you see them once and then you're doing this and they have a whole history around them, which is coronary artery disease, history of stroke, whatever. So I always ask my nurse to communicate with the physician's nurse who's prescribing them and have that kind of a good idea as to what would be ideal from their point of view. The post one I can manage. Yeah, I agree entirely. We systematically get what we call a cardiac clearance. We have written permission basically from the prescribing physician, whether it's cardiologist or neurologist or even a primary care physician sometimes. I think another point, Amit, is you've done something, you've taken off a five centimeter polyp that you've had trouble closing, for example, with electrocautery and you're worried about bleeding and you're thinking about delaying DOACs for several days. Well, that's a good time to get permission to do that. Agree. Yeah, I think that's the hardest is when you coordinate before, Amit. A lot of times they're only thinking up to the procedure day, I find, so that with the coordinating prescribing physician. So I think, and we don't know if we need to keep it longer, but I would say the approach has just really shifted to minimizing any time off, right? So we try to get it back on as soon as possible for all of these, I think. I think the field has shifted that way, at least. And usually next day, usually not same day. Unless I didn't do anything. Agree. On the same day. Right. I think that covers most of the questions. I've answered some of them just by responding, by typing the answer out. So I think we should be good now.

colonoscopy safety

medical-legal risks

informed consent

complications prevention

muscle injuries

hemorrhage prevention

tattoo placement

post-colonoscopy follow-up