This ASG video tip is sponsored by Braintree, maker of the newly approved Suflav and Sutab. So as Kevin said, it's all about preparing. So we're going to look at the lesion very carefully, inspecting it, then we're going to prepare what we're going to do both mentally and with all our equipment, and then we'll talk more about how to resect the lesion. So starting with the looking, obviously high quality colonoscopy is the mainstay of what we do, and that includes looking for these very subtle lesions. And I'll show you a few pictures here. These polyps are very, some of them are very, very subtle. And I don't know how many times I have found a polyp where I just am humbled because I feel like I could have very easily missed it. And sometimes the only clue you get is like this tiny little bit of stool that, you know, it was attached to it. I'm not going to talk about AI, but in my program we actually have AI now, and that also helps you highlight some of the things, these little subtle, subtle clues. Like here you can see there's a little tiny bit of stool adherent and ends up being a very subtle flat lesion. And I feel like some of these pictures aren't even transmitting well, but the point is we have to look very, very carefully. Some of these polyps are extremely subtle. And then not only just finding them, but then looking at the edges and seeing where exactly are the borders. And obviously we can use white light, like in these pictures, and then we're going to have to usually add some sort of enhanced imaging techniques too, like NBI. So if you don't find the lesion, you can't resect it. So step one is find the lesion. Okay. So then once we find the lesions, we need to assess what type of lesions they are. So are they flat? Are they broad? Are they granular, non-granular? And these are all the things that are going to help us decide and plan if we're going to be successful in the resection. So obviously our main goal is to help the patient. So if we're working, spending a lot of time on a lesion that maybe is high risk for deep submucosal invasion, which is going to put us at risk for adverse events, or if we're not even helping the patient because they're not going to need surgery anyway, those are the things that we need to try to plan for before we even start. So as we can see, these lesions have some high risk features, the mixed type with nodules and flat, or if they have features of malignancy involved. So we want to find and identify those flat lesions that may not be successful with endoscopic resection. So things that are ulcerated or excavated, Paris type 3 lesions, if there's a disruption in the pit pattern, those can be signs that this is more malignant or more deeper involved. If it's non-mobile, then you know there's that submucosal fibrosis. There's different tests you can run on the polyp, like lifting it. If it lifts, non-lift, we'll talk about that a little bit more later. Converging folds, you know those folds that you see kind of like pulling in from the side, those are signs that things are kind of going a little deeper. The white spots, I don't really know what the significance of those are, but those are signs that it could be deeper, deeper invasion. So here is a short video showing that this polyp obviously does have signs of not only deeper invasion, but malignancy. And we just have to look very closely at the polyp, the vascular patterns, and use both white light and other enhanced imaging techniques. And some of you may have looked at some of the pictures on the online modules and said, oh my gosh, these are so subtle, I don't know if I can do it. But the truth is, you can. And if you're not comfortable now, you can learn. So this is just a study that was done a while ago, but showing that going from GI trainee, which you're less than 50% accurate, and then if you're an expert, which is what you're doing today, then you can be quite accurate, up to almost 90% accurate, to decide if it's a deeper lesion or a higher risk lesion. So the other thing we need to look for in the polyp, now that we've identified it, we've decided maybe we want to resect it, is what do we know about the polyp's history? So has it been touched before? So as you become experts in advanced EMR technique, you're going to get more referring from your colleagues or from other physicians in the area. And so part of that relationship is training them what you need and what you don't need prior to the referral. So if somebody's tried to work on it, that's going to make it more difficult for us. Tattoo placement, if it is really subtle or you can't describe where it is, maybe tattoo placement from your referring might be helpful. But usually, if you're a careful endoscopist, some of these big polyps, you can find them. So it's not always necessary for your referring doctors to tattoo them. And it actually can hurt because people often put the tattoo too close, and that spreads so widely. You've all seen that. And that tattoo actually causes a lot of fibrosis and will definitely make your polypectomy more difficult. And I've actually been surprised how many people have asked me, oh, you don't tattoo right under the polyp? No. Please do not tattoo under the polyp. So anyway, also aggressive biopsy. I mean, if they're going to refer it to you for resection, probably biopsy is not necessary all the time. But if they are going to biopsy or if you're going to biopsy, just kind of do it not aggressively. Just take a couple of bites usually from the edge is usually the best way to tackle that. All these techniques will cause fibrosis and obviously make your polypectomy more challenging. Okay. So we looked at the lesion. We know we want to try for it. So let's prepare. Do we have all the tools we need? So one of the first steps is choosing your endoscope. So obviously, you want to set yourself up for the best chance of success. So maybe the endoscope you're using isn't the best choice. Sometimes if it's a left-sided lesion, you may want to use an upper scope to allow for more easy retroflexion. Or maybe you want to change to a PCF, something like that. So just thinking about what scope you're using, is that going to be the best one for your success? Snare. So I know there's always a lot of questions about what snare do you use? Well, you use the snare that you're comfortable with. Obviously, there's a lot of different snares on the market and all of them have different techniques or different specialties and different strengths. There's oval, crescent, hexagonal. There's ones with special different tools like the needle, the barbed one, the one with the spiral around it. There's a combination with injection needle, varying stiffness. So you practice with the snare that you like, and then that will become the snare that you use all the time. There's no magic snare that will work for everything. So just be familiar with your toolbox of snares and you probably will have one or two in your toolbox that you like the best. That's a braided snare. Okay, caps can be helpful. I know there's some people that scope, do all their colonoscopy with caps. I don't. But definitely if I'm going to be planning to do an EMR, I will definitely consider adding a cap. I feel like I've never regretted putting it on, but I've often regretted not putting it on. So anyway, the choice is there. So the problem with the cap is that you have to come all the way out. So if you've already decided to do the colonoscopy and then you have to come back out, that can sometimes add more time. But there's a lot of different caps available. They can help with positioning and kind of pushing those folds out of the way. They can sometimes help with visualization of those rims of the polyp. Okay, different hemostatic devices. So APC, I feel like we used to use APC a lot more. APC can be used to ablate the edges of the polypectomy and that used to be our mainstay of technique. Now most of us are using the snare tip soft coag technique and that's because you already have your snare there and it's very easily accessible. It's less costly. And the monopolar forceps also are very helpful for hemostasis and hot avulsion.

colonoscopy

lesion detection

advanced imaging

polypectomy

patient outcomes