I'd like to welcome our next speaker, Dr. Ashley Fox, who is a professor of medicine at Case Western Reserve University School of Medicine in Ohio. She's an advanced endoscopist at the university hospitals, Cleveland Medical Center, and serves as a director of endoscopy at the Cleveland VAMC. Her interests are in management of complex pancreaticobiliary diseases, GI cancers, EMR of early esophageal cancers, and large colonic polyps. And today, she'll be speaking about cold versus hot colopectomies. Thanks, Jo. Hello, all. Welcome. I'm glad to see everybody here. So I just want to let you know, I'm sporting the ASGE compression stockings. See how styling they can be? As long as you put boots over them. Anyway, so I'm getting to that age where I probably need these things, but haven't gone there yet. As my former fellows know, just not so fashionable, unless I'm wearing boots. So I have no disclosure. So this is an area where I've been really interested in. I was very enthusiastic about EOS and ERCP when I first started. And now, about 19 years in, I'm more interested in taking out big polyps. And if I never did another EOS or ERCP, that would be fine. Because the cool thing about it is you can prevent patients from getting surgery, prevent them from getting cancer. And except for esophageal EMR, with EOS and ERCP, we just diagnose cancer. And then a lot of them don't do very well. So not to be so Debbie Downer. But I just think large polypectomy, for those of you who are interested in finding a niche, I think this is a great one. I've been telling fellows this instead of spending a year doing advanced training and then dealing with all of that craziness. Big polyps are great. A lot of groups would love to have someone to send their big polyps to. So if you're looking for something to expand on, this is just an extension of skills you guys already know. So I think it's great. So I'm going to talk a little bit about how I have moved away from hot snare. And I think a lot of people have been doing this. We'll talk about the pros and cons. And I'll maybe try to convince you to try more cold snare, even with big polyps. We'll talk about the risks of both of them and look at some of the data. And then there are some unanswered questions in cold snare. So obviously, there are factors influencing your choice. So polyp characteristics. And we're going to talk about that. I think that that is an area that is really important that I try to emphasize with our fellows. And I mean, I know we all know about these Paris classification, NICE classification. But I think even sort of reviewing examples of these online can be really helpful. Because it's really important. You don't want to send a big polyp to someone. And then they go in and they're like, yeah, that's cancer. And that happens to me. And patients are just like, what? If you just look at it carefully and you're looking at the whole polyp, you may be able to see something. You're like, yeah, I'm not taking this out. So I think that's really important. Also patient characteristics. So we have a lot of patients who are taking these anti-platelets, anti-coagulants. And there may be some more of a risk of stopping than not. So the question is, can you not stop these medications? And I think we are moving towards that more and more. Or when do you restart? Use hot snare. Then you're like, ugh, five days, seven days. And I don't think we really, really know the answer to that. So that can be a challenge. Also endoscopist training and comfort. So obviously, when you're looking at a big polyp, are you comfortable taking that out or not? And if you are, which are you more comfortable with, hot or cold? And then equipment availability, based on do you have injectates, do you have the right snares, and things like that. So we actually have in your little handouts a PARIS classification, which I think is great to have. And I like having it right at the computer, because I don't always remember it. We have so many things. We've got all this stuff to remember. So I think it's really useful. And the important thing is remembering that the 2Cs and the 3s are ones that you may have to think twice about, can you take it out? When you inject, is it going to lift? So very important. And then it helps you risk stratify for submucosal invasion. So we know that these ones that have 2C component are at much higher risk of submucosal invasion versus the homogeneous, granular type. So all these are on your handouts. It's a nice little guide that you can use, a little cheat. You can hold it under the desk if you don't want anyone seeing it. But I think the important thing is really looking at the polyp. And that's something that you just got to keep looking, using near focus. We have a lot of tools on our scopes, near focus and NBI to sort of look at this. And then this is the nice classification. It's a little bit different than the 1, 2, 3. This is the Japanese classification, where what they did was they took 2s, and they said we were not good at differentiating low grade versus high grade. So they've broken up 2 into 2A and 2B. And so, I mean, when you're looking at a type 3, where you see that irregularity and loss of those vessels, you see it smooth out, I mean, you've got to really think about this is probably a cancer, and maybe I just biopsy it and get out. So obviously, the goals of polypectomy, I don't have to tell you, is to remove the entire lesion. But you want to minimize your adverse events. And then ideally, minimize cost. Remove it efficiently, and not have to spend an extra year learning how to do this. So there are the ESD people, and I am not an ESD person. I am a piecemeal EMR person. And I think there certainly is value in ESD, but we know it takes a little more training. Other tools that are more expensive that maybe the place where you're practicing is not interested in buying you an IT knife, or a SB knife, or things like that. So there are sort of these considerations that we have to think about. And then when you take it out hot, we'll talk about clipping and adding to the expense. So why are endoscopists going cold? So we know there are complications related to hot snare, including immediate bleeding, which is oftentimes pretty easily managed, but the delayed bleeding, and then the risk of perforation. So you see this big polyp, and you're like, oh, god, I'm not going to be able to take that one out cold. That is big and bumpy. And then you can see, this is a beautiful picture from Cyrus Paraka, who kind of got me into this, and so did Heiko Pohl. And you can take this out cold, and then you can see that there can be no residual polyp. So I'm going to delete his voice. So we know for polyps less than 10 millimeters, everybody's doing it cold, basically, right? Hot biopsy forceps really should not be used anymore, except for hot avulsion. So if you have those, do not use them. There is no reason to do that. And then, I'm not really a big cold biopsy forcep fan at all. I pretty rarely use it, because I like getting a piece. I like getting the polyp, and I see airy around it, and get the whole thing out. There's never too much, right? There is never too much, except if you can't close the snare. So as you start closing it, and you feel like, OK, it's too much, it's not going to cut through, that's fine. It's just a matter of like, oh, I'm taking too much mucosa. It's not possible with cold snare. So I would just recommend, for these little polyps, I'm sure most of you are doing this using a cold snare. I don't know. I just was not a video game person, so like the forceps, I'm always like, uh, uh, uh. And then you get a piece, and then you're like, did I get it all, and then you go back, and it's like, you know, hours later, you know, my fellows are like, oh, we had a lot of polyps. I'm like, yeah, because you're screwing around with the dumb biopsy forceps, you know? So I am just not a biopsy forcep fan. Not for the esophagus, that's fine. So anyway, you can see here that Cyrus like, you know, got a little too much, only because he thought he wouldn't be able to cut through it, did he change his plan. OK. So can we remove all polyps at all with cold snare? So looking at this data, what's that? Can I ask a question? Yeah. Do you have a preference of what, like for those little dimensions, which snare to use? Well, the original one was the X-Acto, right? That was sort of the first one that came out, and then there's the Captivator Cold. So I use X-Acto a lot for the little ones are easy. I like the shape of it. It's like a little diamond shaped. The Captivator Cold, I really like. It's barbed. I use it maybe for the bigger polyps, and sometimes I then change to the X-Acto for the edges. So it's a little, you know, and really the way that I figured this out is just starting, right? So I started with two centimeters, and I had a fellow actually who was very interested in doing big polyps. So it was his third year, second half of third year. He and I would line them up, and we'd do them together, and we learned stuff together. You know, what injectate I like, what concentration, what did I like, did I like how much epi, you know? And it sort of, you kind of feel as you go, and you don't start with a five centimeter polyp. I mean, that's just silliness, right? You got to start small, build up your confidence, you're like, all right, I'm doing this. And then, you know, you can go to bigger and bigger. So actually, the other day, I seriously did a three and a half hour polypectomy. I've never done that. I did a 10 centimeter rectal polyp, and the patient would have needed an, you know, APR. And so, yeah, it was like, I was just recovered from COVID, and I did that, it was painful. But you know, I didn't start there. You can't start there. You need to start a little slow. So here you can see, looking at the data, that the cold wrist section, the immediate bleeding was very, very small, and severe delayed bleeding was nil. The only time I've had delayed bleeding was one patient who I restarted on a Pixaban that day because I was getting overly confident, maybe. I don't know. I never quite know. And he really didn't need to. He was like AFib and not high risk, and I should have waited. But other than that, I've not had problems. So what about larger polyps? So sort of recent meta-analysis in GIE in 2019 showed excellent results with cold snare with regards to polypectomy bleeding, completeness, resection rates, and residual polyp rates. So a recent randomized control trial by Doug Rex and Heiko and others, there was 235 patients randomized to cold snaring, cold EMR, hot snaring, or hot EMR for non-pedunculated polyps 6 to 15 millimeters in size. And actually, the incomplete resection rate was 2.4%, but zero for cold snare polypectomy. So it required less time and no serious adverse events. So cold EMR for large serrated lesions is really typically pretty easy because these don't have much semicosal fibrosis. I sort of have this theory that when you have these polyps on a fold, sometimes you have that linear band of fibrosis. I think it's because the polyps like doing this every time things go through. And so you get that fibrosis. And with these really flat serrated lesions, you typically don't have that. So these are really easy to take out. Some large studies reported no serious adverse events. But we do have to worry about residual polyp because this is seen in these lesions. And it may be a little bit, are we using contrast agent? Because the contrast agent, you've injected a polyp you thought was small, and then you're like, whoa, there's a lot more that I didn't realize was there. So really figuring out a good contrast agent, I really loved Doug Rex would just take a bag of head of starch and put two amps of methylene blue in it, and you just use it all day. But we sort of, that multi-use thing, we got a little, put it on the kibosh at the VA because they thought I might get in trouble. But the fellows used to use it all the time. We'd just sit it in the core, and we'd all just take syringes off. It's like a perfect color, I totally love it, and it's super cheap. But now we're sort of stuck with these other agents that are fine, they're just maybe not the blue that you want. I don't know if you guys agree. I sometimes throw a little more methylene blue in. I would love to encourage these companies to make a little darker. I've been told that the reason it's lighter is because the ESD people say if it's too dark, they can't see the vessels. So that's unfortunate because I think there are so many of us who don't do ESD who would love a little darker. So I'm putting it out there, any reps in the audience? So we know that cold snare is safe and effective for these non-pedunculated polyps that are less than 20 millimeters. And there is really more and more data. This is from Michael Bork's group down in Australia, and it was like seven centers. And they really showed very little incomplete resection or recurrence, minor adverse events, or small and no serious adverse events. So I would just try to compel you to say that this is possible. So when we're looking at hot snare, post-polypectomy bleeding rates are not insignificant, they're not huge, but around 2% to 7%. And then there are some evidence that closing the defect if you are on the right side of the colon and it's greater than 2 centimeters can significantly decrease post-polypectomy bleeding. So I mean, the issue is you take out these big lateral spreading things. I mean, you got to clip the base and then clip over. And it's like a lot of time, you see all those clips, hundreds of dollars, thousands of dollars in clips. Worth it, obviously, if you're worried about bleeding in a hospital visit or perforation. But it does take a lot of time. So very time consuming, expensive. And then the question is, because I was actually asking Doug Rex about this, when you take out those big wide things, how do you close that? So he would clip along, kind of bring it together, and then clip again. And so if you left anything at the base, are you burying that so when you go back to do surveillance, are you kind of screwing yourself? So it's not quite clear if that's the right strategy. But there is an ongoing randomized controlled trial for these larger polyps. So for prevention of post-polypectomy bleeding, if you do go hot, this was a meta-analysis that was recently published to assess the efficacy to prevent these adverse events in larger polyps. It included four randomized controlled trials. Examined right-sided lesions were bleeding after hot scenarios most common. And clipping was effective in preventing post-EMR bleeding regardless of patient factors. But the question is, is cold snare going to be a game changer? So post-polypectomy bleeding, I would say, is pretty rare in cold snare. I use epinephrine. So I used to use 1cc in 10, and I thought that was great. But then I noticed that patients were having pain sometimes after. So when you do cold snare, you're like, well, I know I didn't perforate. I know I don't have post-polypectomy syndrome. It's like they're laying out there and having pain. And I've had this with duodenal polyps as well. So what I think it is is this local ischemic effect that the epi has. It goes away. But initially, patients will go to the ER and be convinced that doctors will be getting CAT scans and everything else. So I've gone to really a few drops of epi because I just really think that it may prevent some of the oozing really just to make sure you get a good resection. So really, when you think about using epi for these, if it's a pedunculated polyp, that's a little bit different. You might epi the stalk. You might epi the head to help with really keeping things from bleeding while you're resecting. But I personally think that putting a little bit of epi, not a lot of epi, is really good. I can't tell you the concentration. Honestly, I do a couple of drops now because you really can see how pale the mucosa gets. So there is very little risk of perforation in these patients. Now some people do this, and they think this is great. They're just yanking the snare when you can't cut through. And I do see people do it, and I have colleagues that do it. I would say on the right side of the colon, I would not do that. I think that means you have some submucosa there, and you risk causing that perforation. So you want to open the snare a little bit and then reclose. And if you can't get it, you've got to take the snare off and try, you know, go with something different. You know, and sometimes you're doing the whole thing cold, and you get to that fibrotic band, and you can't do anything about it. You know, sometimes you have to get the hot forceps out and do a little hot avulsion, which is a great technique. But release and regrab is a good idea. So again, this is from Heiko, looking at all the data on cold snare. You can see bleeding, perforation, post-palpectomy syndrome, 0, 0, 0. So pedunculated polyps, I guess I would say I typically take out hot. But I have those moments where, you know, I've been using cold, and patient has a polyp, and it's a little guy. And I'm like, eh, I'll just cut right through it because, you know, it looks like it's safer. There's, you know, less risk of bleeding when you use cold. However, I have noticed, I mean, just personal experiences that I clip it, and then it just starts bleeding. And I'm like, all right, then I use a clip. So you know. So think about it. It's not, you know, if the stalk is thick, it's not going to cut through, and there's probably a big vessel there. But this little guy in the corner, you could cold snare that off. And you know, I also do the tamponade thing with the water jet. You hit your foot, and you know, you go right into the defect. I do this with all my polypectomy to make sure I got the whole polyp out. But also, it does tamponade. And you know, sometimes just being a little patient, and just, you know, it'll stop, usually. So talking about cold snares on the market, this is a hot, hot area. You know, Microtech has now come out with, I think, a little bit of a bigger one. X-Acto has a 15. I don't think I've ever used it, actually. But they have the original 10. I love the 10 Captivator Cold. These tend to be very stiff snares, at least the X-Acto and the Captivator Cold. So when you go up to the polyp, you sort of press down, and the polyp goes up, and then you close. I also have modified my practice. I don't use anything bigger than a 15 millimeter snare, because you don't want to be taking big pieces hot, I guess what I'm talking about. Because that will increase your risk of perforation. And I actually, I was at a course, the Rocky Mountain course, and I was sitting next to Michael Bork, because I was giving a talk, or on a panel with him. And I really, like, pumped him for information. He probably never wants to sit next to me again. But what I found out from him was the issue of using a little bit of Epi, you know, mostly to clear the field, and also that he doesn't use anything bigger than 15 millimeters. So I came back to my home institution, and I, like, all right, we're not buying these, you know. So, you know, it's these little things you pick up as you go, and talk to faculty and your colleagues what people are doing, because, you know, there's no right way or wrong way to do these things, and you just have to sort of figure out what you like and try different things, and then you'll figure out sort of what works for you. So, you know, what polyps can we tackle? And this is a great video from Cyrus. And you know, you see this big bulky polyp, you're like, oh no, I cannot take that out with cold. But it is amazing. You see, you start, you use the cap. There's like pros and cons to cap, but I always use them if I'm going, like, ileocecal valve. Sometimes the flexors are helpful. But you can see, he's injected, and you see where the snare is? You got to get a little normal and a little abnormal. So I always try to sort of half and half. Try and get all the edges, because there's data that the edges seem to be where the recurrence is. I also snare at the base. So you finish the whole thing. You see a little stuff here and there. Don't be afraid to snare the base. You can do that. It's like that sort of fluffy white submucosal tissue. So you can see here how this polyp that looked big and bulky as you inject it. You know, sometimes people say, oh, there was depression in this polyp. Well, you know, the folds. It goes along folds. If you inject it, it sort of flattens out. So here, you can see how lovely this is. I would snare, you know, that center, fluffy white stuff, I would snare that out. So don't be afraid to snare at the base. It's really safe to do. Again, starting with these harder edges and trying to see if I can show my mouse. All right, well, I don't know, not working. Okay. Oh, yeah, I forgot about that. So, again, you see this polyp looks like a lovely little SSA now. Look how the snare is, right? It's putting it half normal, half non-normal. You can go wide. You can take a little polyp and just go crazy. Really, the risks are so, so low. And so just try to go around and get a nice edge. And again, progressing with overlapping pieces. Try not to leave islands. They're kind of a pain to deal with. So it's much easier if you're just very methodical. And the important thing is the scope has to be straight. So that's the rule for me, for my fellows. If they want to start doing big polyps, they have to be able to get to the secum straight or no dice. And again, can these big bulky polyps be removed? And as you can see, as you just start going, and it does not take a long time. It's in more pieces than hot snare, but it really doesn't take a long time. And if you're straight and you're methodical, it's pretty quick. So I think there is this cold revolution. Cold snare is really standard for these less than 10 millimeter polyps. Again, using a good injectate, making sure you see the margins of the polyp is really, really important. And start practicing. Start small. And then you can sort of move on to big. I think it's a great niche. As we do these stool studies where we're only doing, it's sort of like MRCP supplanting diagnostic ERCP. We may not be doing diagnostic colonoscopies, just therapeutic. So I think it's a great area. And then there's this large polyp study that Heiko and Doug Rex and Cyrus are doing and Holly Rapici. So I think there'll be more data coming out as we go. Okay. Thank you. So now for my quiz, because I didn't get questions in. Okay. First question. I don't have a poll everywhere, but you can just yell it out. How much did Americans spend this year on Halloween costumes for their pets? A, 100,000. B, a million. C, 7 million. And D, 700 million. What do you guys think? What? C? 700 million dollars. Think of how much we could do in healthcare with that money. And they're probably going into the landfill if you want to go green, you know, really? Okay. According to Forbes magazine, what is the most popular Halloween candy? Reese's peanut butter cups. All right. Thank you, guys. Thanks, guys.

Dr. Ashley Fox

medicine

Case Western Reserve University School of Medicine

cold colopectomy

hot colopectomy

large polyps