I have a question for Dr. Faux. How often do you do soft-tip coag at the margins after your polypectomy, and what makes you decide to or not to? So if I'm already doing hot, I guess I will. If I'm not, I usually just try to cold snare around the margins, because I just find it impossible to believe that if I have normal-looking margins and I cold snare around it, that there's going to be residual there. Like I think maybe sometimes it is the base, but I think they've done some studies looking at biopsying the middle, biopsying the edge, and the edge seems to be it. But if I'm already using heat, I guess I will do it, unless, you know, I mean, the rectum's really easy. I usually use hot in the rectum, because the risk of causing problems is low, and then if they bleed, it's right there. But there is good data on that, for sure, and it decreases the risk of recurrence. But with cold, you know, then you're like, is it really cold? And, you know, talking to one of my colleagues, like, I did this big, cold polypectomy, and he bled. And I was like, oh, really? He's like, well, he's a little hot, you know? So I mean, you know, I think there is good data for that, for sure. So if you already have your hot snare out, I think it's a good idea, and it's quick and easy. I think it's, make sure you have your setting on your generator for that. Yes? I have two practical questions. Number one, are you consenting your colonoscopy screening or surveillance patients for EMR at the time of their index procedure? And number two, what determines, well, I guess a couple of questions. Number two, what determines whether or not you will do an EMR that you happen to find during that colonoscopy? And number three, if you are set up for a colonoscopy that you know you have to do an EMR, what is your standard time that you allocate for that? So the three and a half hour rectal polyp, I gave two hours. So that was a bust. But, you know, they get bigger sometimes, you know, if you start resecting, you're like, oh. So I do not consent my patients specifically for that, and now I am sort of one of these weird people that does moderate sedation. So my patients, I like them to be awake enough to move and hold their breath, because, you know, sometimes it's a flexure. Anesthesia is like propofoling in their, you know. So I just talk to them. I'm like, oh, you see this polyp? I just do it. I just, were it you, what do you want? You're going to be like, oh, bring me back and re-prep? You guys, any of you guys had prep? It's terrible. So I think, you know, and also I work a lot at the VA. I mean, you know, we're just happy to get them in once. So we're not going to send them out. So I just do it. And usually, I mean, the advantage of the VA, if you guys, anyone has ever worked there, you know, it's like sort of this, everybody comes in and you just dole them out as they, you know, some of them are for me, but otherwise just dole them out. So I just do it. And, you know, I have easy colons where there's no polyps and you're done in 15 minutes. And so you get a little time from that for the other. So I don't consent separately, no. I mean, I just tell them, you know, if we find a big polyp, we'll take it. You know, but I do like them a little bit awake. But otherwise, like, you know, if they're really big polyps, I will, I mean, if they're big, I guess I would do an hour. I mean, when they're really, really big, apparently you need three and a half, but who knew? We at our ASC, we scope it at ASC, and then we also scope at the, at our in-hospital medical or endoscopy unit. And so at our ASC, we've incorporated into our standard colonoscopy consent EMR because the risks, the main risks are really a perforation rate of, you know, about 1% and a bleeding risk of anywhere from 5% to 10% up to three weeks. And so we've incorporated that into it. But you know, so sometimes when I'm at the ASC, it depends on who my tech is. We don't have the same complement of tools available at our ASC, and we have 30-minute colon slots. So if I'm like running ahead, and it's like a two-centimeter thing, I could bang it out. But a lot of times, just because of how the schedule is, how your support is, I'll bring them back to do a formal one. I mean, I think that's not uncommon for people to do it. I just sort of a little bit have the luxury of, I mean, we actually just changed Epic and they have, they can't seem to figure out how to like make the blocks longer. So now they're every half hour. So I don't know what I'm going to do there because I, yeah, I guess we'll see. But no, I just feel bad making patients prep again, I guess. And so, you know. The ASC of everyone is that you don't have to tackle it and then be like, I'll come back. Right. Do it all or do nothing. Right. Or you can inject it. So that's the other thing that I tell people, you can inject it. I mean, if you inject it with, you know, lifting agent and it doesn't lift, then you've done no harm. It's just, yeah, starting to mess with it and then you can't get it out. That's a really a pain in the neck. So then that requires other techniques that, you know, it just, it ends up patients get more colonoscopies than they should because you're just having a hard time getting it out. So. Any other questions for us? But I'll be around if you guys want to ask me questions because I really, it's been a fun, you know, adventure for me and sort of, you know, figure out how to do all this. This question is actually for Dr. Conda about Bart's esophagus. So we've had these reps come through regarding this like genetic testing to risk stratify patients. I just want to know your thoughts on that. Sure. So tissue cipher is a commercially available test for risk stratification. It basically looks at 16 different kinds of features on the archival specimens. You don't have to repeat an endoscopy. You could take the pathology requisition and they cut additional slides and send it over. And it allows for all those features to be assessed and then there's a risk score that's determined and a probability over five years of progression and classification for like low, intermediate, and high. I think it is a useful tool in the right patient. So I do use it especially when I'm trying to help risk stratify patients with low-grade dysplasia, indeterminate, or non-dysplastic Barrett's that might otherwise be harboring some high-risk features. I'm not going to do it on patients I already know my plan because that's like I have a high-risk low-grade and with a visible lesion I'm already deciding to plan for therapy. That's not going to change my management. But it's really good for the equivocal cases of a confirmed low-grade that might not really want to undergo therapy and they just need something else to help push them over the edge. I find that that's useful. Someone with persistent indefinite dysplasia, which is technically indefinite dysplasia is not an actionable diagnosis. It's technically a transient diagnosis, but sometimes you're like sitting on the fence and you want to get more information. So those are the kinds of places I use it.

soft-tip coagulation

polypectomy

EMR

colonoscopy

Barrett's esophagus