Gastroenterology & Endoscopy

Join us for a deep dive into the cutting-edge world of polyp reshaping in colonoscopy. In this episode of The Gastroenterology & Endoscopy Podcast, we explore how these advanced techniques are transforming colorectal cancer prevention.

Key Topics:

1. The Evolution of Polyp Management
   • From "detect and excise" to a nuanced, multifaceted approach
   • Balancing precision, risk minimization, and colonic function preservation
2. Cornerstones of Effective Polyp Reshaping
   • Advanced classification systems: Paris classification and beyond
   • Cutting-edge imaging techniques: NBI, CLE, and pit pattern evaluation
   • The importance of size stratification and location considerations
3. Revolutionary Reshaping Techniques
   • Endoscopic Mucosal Resection (EMR): Injection-assisted, cap-assisted, and underwater variants
   • Endoscopic Submucosal Dissection (ESD): Achieving en bloc removal of large lesions
   • Full-Thickness Resection (EFTR): Tackling lesions involving the muscularis propria
4. The Future is Now: Emerging Technologies
   • Artificial Intelligence in polyp detection and characterization
   • Advanced imaging: Optical coherence tomography and molecular imaging
   • Innovative devices: From microwave ablation to biodegradable clips
5. Personalized Approach to Technique Selection
   • Considering lesion-specific factors, patient profiles, and endoscopist expertise
   • The role of multidisciplinary tumor boards in complex cases
6. Post-Resection Care and Long-Term Success
   • Precision histopathology and risk-stratified surveillance
   • Managing complications with cutting-edge solutions
7. Challenges and Future Directions
   • Standardization of quality metrics
   • The promise of multi-omics data integration
   • Ethical considerations in AI implementation

Why Listen:

• Gain insights into state-of-the-art polyp management techniques
• Understand how these advancements are improving patient outcomes
• Learn about the future of endoscopic interventions in colorectal cancer prevention

Expert Insight: "Every reshaped polyp represents a potential life saved, bringing us closer to a world where colorectal cancer is no longer a leading cause of cancer-related mortality."Resources Mentioned:

• Paris classification system for polyp morphology
• Kudo's classification for pit pattern evaluation
• Narrow-band imaging (NBI) and confocal laser endomicroscopy (CLE)

Polyp Reshaping in Colonoscopy

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Welcome to our podcast on endoscopic resection of Zenker's diverticulum. Today, we'll dive deep into this condition, its treatment, and the benefits of endoscopic approaches.

Zenker's diverticulum is a rare disorder of the esophagus, primarily affecting elderly individuals between their 70s and 90s. It's more common in men and occurs in about 0.01% to 0.11% of the population, with higher rates in northern Europe, the United States, and Canada[1].

This condition involves a pouch forming in the hypopharynx, typically between the cricopharyngeus (CP) muscle and the inferior pharyngeal constrictor muscle. It's a false diverticulum, meaning it only involves the mucosa and submucosal layers, not the muscular layer[1].

The exact cause isn't fully understood, but it's believed to result from abnormal pressure during swallowing, causing a weakness in the Killian triangle - the area between the horizontal and oblique fibers of the cricopharyngeus muscle[1].

Patients typically present with a long history of dysphagia, or difficulty swallowing, which occurs in up to 98% of cases. Other common symptoms include regurgitation, halitosis, aspiration, and recurrent coughing[1].

Traditionally, Zenker's diverticulum was treated with open surgery or rigid endoscopic techniques using a laryngoscope. However, these methods require general anesthesia, tracheal intubation, and are more invasive, leading to higher complication rates and longer hospital stays[2].

In recent years, flexible endoscopic treatment has emerged as a superior option. This approach offers several advantages:

1. It's less invasive, reducing patient discomfort.
2. It requires a shorter hospital stay, typically around 2 days.
3. Patients can resume oral food intake the day after treatment.
4. It has lower complication and mortality rates compared to traditional methods[2].

Now, let's discuss the key steps for performing an endoscopic resection:

1. Use of a transparent cap: This is attached to the endoscope tip. It stabilizes the view, maintains a safe distance from the tissue, and allows for precise incisions.

2. Ensuring clear visualization: The esophageal lumen and diverticulum should be clearly visible. If visibility is difficult, a guidewire or thin tube can be placed into the stomach to maintain a clear view of the esophagus.

3. Choosing the right tools: Various devices have been examined for this procedure. A hook knife is often preferred as it allows for controlled cutting and dissection of muscle fibers. Other options include argon plasma coagulation, different types of needles, stapling devices, and endoscopic scissors[3].

4. Performing the septotomy: This is done in stages. First, incise the mucosa, then the submucosa, and finally the muscle fibers. It's crucial to proceed slowly and steadily. The goal is to cut the cricopharyngeal muscle, which is the main objective of the treatment.

5. Safety closure: After dissecting to the base of the septum, place a closing clip at the apex of the dissection. This is the most vulnerable area for perforation. A clip with a short stem is preferred to avoid irritating the opposite wall.

It's important to note that this procedure is challenging and should be performed by endoscopists with high expertise in therapeutic endoscopy. It requires special training, which can be difficult to obtain due to the rarity of the condition[2].

The benefits of endoscopic treatment are significant. Patient satisfaction is reportedly very high, with patients appreciating the non-invasive nature, short hospital stay, and high rates of dysphagia resolution. Even in cases of symptom recurrence, the procedure can usually be repeated effectively[2].

In conclusion, endoscopic resection of Zenker's diverticulum represents a

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In this in-depth episode, we dive headfirst into one of the most polarizing topics in modern gastrointestinal medicine - the heated debate between cold snare polypectomy (CSP) and hot snare polypectomy (HSP) techniques. 

Our host provides a comprehensive overview of these two pivotal polyp removal methods, exploring their pros, cons, and appropriate use cases. We learn about:

• The fundamentals of CSP and HSP 
• European guideline recommendations for each technique based on polyp size
• Comparative data on complete resection rates and complication profiles
• Managing challenges like bleeding and tissue injury
• The critical importance of polyp retrieval and histopathological analysis
• Potential future advancements in endoscopic tools and techniques 
• Adhering to best practices and clinical guidelines

Key Takeaways:

- CSP shows a superior safety profile for diminutive (<5mm) and small (6-9mm) sessile polyps
- HSP provides coagulation benefits for larger polyps (10-20mm) and bleeding control 
- Both methods demonstrate comparable resection completeness for 4-10mm polyps
- HSP carries higher risks like delayed bleeding and deep thermal injury
- Polyp retrieval quality is high with both techniques for accurate diagnosis  
- Technique choice depends on balancing polyp factors and patient needs
- Ongoing research and new technologies will further refine polypectomy

Whether you're a seasoned endoscopist or just getting started, this episode provides invaluable insights into optimizing polypectomy outcomes through the judicious application of CSP and HSP. Join us as we unpack this critical clinical debate.

Links:

• Cold Snare vs Hot Snare: Polypectomy Facts
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6506415/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10246601/
• https://www.gastroenterologyadvisor.com/colorectal-neoplasia/cold-vs-hot-snare-polypectomy-yields-more-favorable-outcomes-for-colorectal-polyps/

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The Couinaud classification is a vital tool in the field of hepatic surgery and diagnoses. It offers a comprehensive understanding of the functional anatomy of the liver by dividing it into eight independent segments. Unlike other classification systems, Couinaud classification focuses on the liver's functional aspects rather than its external appearance.

Key Takeaways:

• The Couinaud classification divides the liver into eight independent functional units called segments.
• The classification aids in precise surgical resections and accurate diagnoses.
• Each liver segment has its own dual vascular inflow, biliary drainage, and lymphatic drainage.
• The Couinaud classification is widely accepted and used in clinical practice.
• It is important for healthcare professionals involved in hepatic surgery, diagnoses, and radiology to understand and apply the Couinaud classification.

Couinaud's innovative approach to liver segmentation has become a cornerstone in modern hepatic surgery, guiding surgeons in planning and executing procedures with utmost accuracy. By preserving the functional integrity of individual liver segments, surgical resection can be performed with optimal outcomes, enhancing patient recovery and long-term prognosis.

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Episode Overview

• Discussion on the endoscopic resection of a laterally spreading tumor (LST) in the ascending colon.
• Examination of a flat polypoid lesion larger than 10 mm, classified as an LST.

Key Steps in Resection Planning

1. Determining the Lesion's Location: Found between two folds.
2. Analyzing Morphology: Identified as LST-granular.
3. Surface Analysis: Using high-definition white light and narrow-band imaging, revealing a regular, cerebroid mucosal pit pattern without ulcers or depressions (Kudo IIIL).
4. Maintaining Visibility: Employing a "suction" mark technique to keep track of the polyp.

Resection Techniques

• Comparison of "cold snare" and "hot snare" techniques.
• Preference for endoscopic resection using interventional chromoendoscopy.

Interventional Chromoendoscopy

• Submucosal injection with a blue colorant to differentiate tissue types.
• The concept of using colorings to guide therapeutic interventions.

Resection Process

• Using a snare to estimate lesion size and achieve complete entrapment.
• Achieving an endoscopic R0 resection by applying electrosurgical current.

Links:
https://www.thepracticingendoscopist.com/p/endoscopic-resection-of-lst-in-ascending-colon
[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6353652/
[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8984535/
[3] https://www.linkedin.com/posts/klaus-monkemuller_endoscopic-resection-of-lsts-precise-localization-activity-7159200748767989760-w1yU
[4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7280838/
[5] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5308134/
[6] https://www.sciencedirect.com/science/article/pii/S2468448121002034
[7] https://twitter.com/EndoCollabcom/status/1753775490068832549
[8] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4414758/
[9] https://www.wjgnet.com/1948-5190/full/v14/i3/113.htm
[10] https://www.elsevier.es/en-revista-ge-portuguese-journal-gastroenterology-347-articulo-large-colorectal-lesions-evaluation-management-S2341454516000107
[11] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8132716/
[12] https://www.mayoclinic.org/medical-professionals/digestive-diseases/news/reducing-post-polypectomy-bleeding-events-in-patients-who-require-antithrombotic-agents/mac-20479873
[13] https://www.giejournal.org/article/S0016-5107(20)34187-0/fulltext
[14] https://dmr.amegroups.org/article/view/8102/html
[15] https://www.researchgate.net/publication/260217120_Interventional_chromoendoscopy_Specific_aspects_for_the_colon
[16] https://journals.lww.com/ajg/fulltext/2017/10001/risk_factors_for_delayed_colonic_post_polypectomy.527.aspx
[17] https://www.sciencedirect.com/science/article/pii/S0016510720341870
[18] https://www.giejournal.org/article/S1096-2883(11)00003-9/fulltext
[19] https://karger.com/ddi/article/37/5/364/95746/Accuracy-and-Pitfalls-in-the-Assessment-of-Early
[20] https://www.dovepress.com/pathological-analysis-and-endoscopic-characteristics-of-colorectal-lat-peer-reviewed-fulltext-article-CMAR
[21] https://journals.lww.com/ajg/fulltext/2020/10001/s3373_endoscopic_mucosal_resection_of_a_lateral.3371.aspx
[22] https://www.linkedin.com/posts/endocollab_endoscopic-resection-of-lst-in-ascending-activity-7159541656394887168-cv5C
[23] https://bmcgastroenterol.biomedcentral.com/articles/10.1186/1471-230X-10-135
[24] https://www.frontiersin.org/articles/10.3389/fmed.2021.728704/full
[25] https://tcr.amegroups.org/article/view/48812/html

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In this episode of the Gastroenterology and Endoscopy podcast, we explore the importance of understanding and mastering different types of polypectomy snares in the endoscopic field. Not all lesions are the same, and using just one type of snare for all scenarios is often ineffective. We discuss the advantages of snares with expansial memory and hexagonal or oval snares with double buckles. The range of polypectomy snares available is vast, and each endoscopist will discover the snare that best suits their needs through practice and personal preference. Factors to consider when selecting a snare include the lesion's size and shape, the snare's ability to retain its shape and durability, and personal comfort and proficiency. Understanding and experimenting with various polypectomy snares enhances the ability to adapt to different clinical situations and leads to improved patient care.

Understanding Polypectomy Snares: A Guide for Endoscopists

Polypectomy snares are critical tools in the armamentarium of an endoscopist, and it’s essential to become adept with at least two types due to the variability in lesion sizes and shapes. A single snare type cannot accommodate all scenarios. Here’s a closer look at the diversity of snares and their functionalities:

• Expansile Memory Snares: These snares are particularly notable. I favor using snares equipped with a robust expansile memory. This feature ensures the snare retains its shape and efficiency even after multiple uses.
• Hexagonal or Oval Snares with Double Buckles: Snares of this design tend to maintain an expanded state very effectively. This characteristic is valuable in ensuring consistent performance over repeated procedures.

However, it’s crucial to remember — there’s a plethora of tools available. Each endoscopist will, through experience and preference, determine which snare aligns best with their practice. Let’s delve into some of the key factors to consider:

1. Lesion Size and Shape: The dimensions and morphology of the lesion dictate the type of snare required.
2. Snare Memory and Durability: A snare that retains its shape after multiple uses is highly beneficial.
3. Personal Comfort and Skill: Ultimately, the choice often boils down to what the endoscopist finds most efficient and comfortable to use.

In summary, while the variety of polypectomy snares may seem daunting, understanding their unique features and testing different types can greatly enhance an endoscopist’s proficiency and adaptability in managing diverse lesions.

Timestamps

• 00:22 - Importance of Multiple Snare Types
• 00:44 - Advantages of Snares with Memory
• 00:55 - Features of Hexagonal and Oval Snares
• 01:05 - Factors in Snare Selection
• 01:37 - Conclusion and Significance of Snare Variety

Keywords
Gastroenterology, Endoscopy, polypectomy snares, tools, techniques


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In this episode, we delve into the intriguing world of Cameron lesions, a medical condition first identified in 1986. We explore what these lesions are, their causes, how they are diagnosed, and treatment options. This episode is a deep dive into the intricacies of medical diagnostics and highlights the importance of detailed observation in the field of gastroenterology.

Key Points Discussed:

1. Introduction to Cameron Lesions: Understanding what Cameron lesions are and their association with hiatal hernia.
2. Historical Background: The discovery of Cameron lesions by Cameron and Higgins in the 1980s and their relevance in patients with a portion of the stomach above the diaphragm.
3. Causes of Cameron Lesions: Exploring mechanical trauma, friction at the level of constriction, and other contributing factors like pressure differences during respiration and gastric acid.
4. Prevalence and Diagnosis: Discussing the prevalence of Cameron lesions in patients with hiatal hernias and the role of esophagogastroduodenoscopy (EGD) in diagnosis.
5. Challenges in Diagnosis: Understanding why Cameron lesions are often missed in initial EGDs and the importance of special attention during examinations.
6. Treatment Options: The mainstay of treatment with proton-pump inhibitors (PPIs) and the necessity of iron supplementation.
7. Conclusion: Emphasizing the significance of Cameron lesions in patients with large hiatal hernias and the need for a high index of suspicion among endoscopists.

Recommended Resources:

• https://endocollab.com/blogs/gi-endoscopy-tips-tricks/cameron-lesions
• https://www.thepracticingendoscopist.com/p/cameron-lesions

Timestamps:

- 00:00 Introduction to Cameron Lesions
- 00:12 Definition and Association with Hiatal Hernia
- 00:29 Discovery and Prevalence
- 01:09 Causes of Cameron Lesions
- 02:01 Diagnosis and Challenges
- 02:37 Treatment and Management
- 02:55 Association with Iron Deficiency Anemia and GERD
- 03:05 Significance and Importance of Cameron Lesions
- 03:26 Conclusion

Keywords:
Cameron lesions, hiatal hernia, gastric mucosal folds, mechanical trauma, local ischemia, mucosal stress, ulceration, EGD, proton pump inhibitors, iron deficiency anemia, GERD, size, overlooked, high index of suspicion

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In this episode of the Gastroenterology and Endoscopy Podcast, we explore the world of water-assisted colonoscopy (WAC). WAC is a technique that uses water instead of air or gas during the insertion phase of a colonoscopy, offering numerous benefits for both endoscopists and patients. By utilizing water's natural properties, WAC can reduce pain and discomfort, straighten out the colon, and enhance visibility of the mucosal surface. This technique not only improves patient comfort but also plays a crucial role in colorectal cancer prevention by improving adenoma detection rates. Join us as we delve into the advantages of WAC over traditional methods and its potential impact in the field of gastroenterology.

Quotes

• 00:00:46 - "Studies have shown that water assisted colonoscopies can significantly reduce the pain associated with colonoscopy."
• 00:03:35 - "To sum up, water is not just an alternative for colon distension in colonoscopy, it's an essential component that significantly elevates the effectiveness of the procedure."

Resources

• Water Assisted-Colonoscopy (WAC or Hydrocolonoscopy)
• Do You Use CO2 and Water Immersion in Diagnostic Colonoscopies on a Daily Basis?

Keywords
water-assisted colonoscopy, WAC, hydrocolonoscopy, benefits, endoscopists, patients, concept, application, water, air, gas, insertion phase, colonoscopy, pain, challenging cases, colonoscope, bends, loops, straightening, angulations, gravitational effect, colonic elongation, loop formation, discomfort, sedation, water irrigation, visibility, mucosal surface, adenomas, precancerous growths, ADR, colorectal cancer prevention, air insufflation, water immersion, water exchange, duration, modified version, partial WAC, CO2, combination, tight angulations, colon elongation, cleaning, lumen, folds, polyp detection, modern colonoscopes, water jets, hybrid technique, suction, liberal use, overall quality, water, cleaning, mucosal surface, colonoscopy, debris

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In this episode of the Gastroenterology and Endoscopy podcast, we discuss a challenging case involving a pedunculated duodenal adenoma. These types of polyps present unique challenges for endoscopists, requiring meticulous planning for a successful procedure. The goal is to achieve a complete R0 resection, removing the entire lesion without leaving any microscopic remnants. We explore strategies to prevent migration of the polyp into the bowel, such as positioning the patient in a decubitus supine position or using an antimotility agent. The endoscopist and assistant must be on high alert to catch the polyp with the snare, and having a Roth's net on standby is recommended.

Chapters:
[00:02:16] Preventing complications.

[00:04:10] Preparation is key.

Resources:

1. Endoscopic Resection of Complex Duodenal Polyps
2. Duodenal Polyp Resources on EndoCollab

Quotes:

• 00:02:52 - "By allowing the neoplasm to float, we reduce the chances of transmitting electrosurgical current to the base of the lesion, minimizing the risk of perforation."
• 00:03:06 - "And when it comes to closing the wound post-resection, clips are a must."

Topics Discussed:

1. Introduction to Pedunculated Duodenal Adenoma: Brief description of the polyp’s location and importance of meticulous planning for resection.
2. Achieving Complete Resection (R0): Importance of removing the entire lesion and considerations to make during resection.
3. Preventing Polyp Migration: Strategies to prevent the polyp from moving into the distal bowel.
4. Complication Prevention: Discussion on measures to prevent complications during and after endoscopic resection.
5. Tools and Techniques: Exploration of various tools (snare, Roth’s net, distal transparent cap) and techniques (submucosal injection, underwater resection, use of endoloops and clips).
6. Managing Immediate and Delayed Bleeding: Importance of using endoscopic clips and hemostatic hydrogels, especially in patients on anticoagulation.
7. Proximity to the Papilla of Vater: Ensuring correct identification of the lesion’s location and planning the resection accordingly.
8. Post-procedure Care: Importance of starting proton pump inhibitors post-procedure.
9. Final Thoughts and Goodbye: Summing up the key takeaways from the episode and bidding farewell to the listeners.

Keywords:
Gastroenterology, Endoscopy, pedunculated duodenal adenoma, endoscopic procedures, complications,closing the wound, post-resection, clips, duodenal endoscopic resections, bleeding complications, hemostatic hydrogels, Puristat, anticoagulation, proton pump inhibitors, healing process, polyp's proximity, papilla of vater, ampullary lesion, resection, side-viewing endoscope, complete R0 resection, pedunculated duodenal adenomas, preparation, plan, outcome, patient, insightful, helpful, practice

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In this episode, we discuss the importance of improving colonoscopy prep and achieving better Boston bowel preparation scores. Colon cancer is the second leading cause of cancer death in the US, but it is preventable through colonoscopies. However, the success of a colonoscopy relies heavily on proper bowel preparation. Inadequate prep can decrease polyp detection rates by 27%. Patients are advised to follow a special diet and take a bowel cleansing solution prior to the procedure to ensure a clear view of the colon. The cleanliness of the colon is graded using the Boston Bowel Preparation Scale, with a minimum score of 6 recommended for optimal polyp detection. Unfortunately, the endoscopy center discussed in the episode noticed alarmingly low Boston prep scores among their patients.

Quotes:

• 00:00:29 - "They allow doctors to have a clear view of the entire colon, catching precancerous polyps before they develop into cancer."
• 00:04:13 - "The results of these changes have been nothing short of transformative."

Chapters:
[00:01:45] Importance of Boston bowel preparation.
[00:04:25] Thorough colonoscopy PrEP is indispensable.

Read more: 

• Improving Colonoscopy Prep and Achieving Better Boston Bowel Preparation Scores
• Can I have your experience with colonoscopy prep? I have noticed that most of the patients we receive don't have a good Boston score?
  
  

Keywords:
colonoscopy prep, Boston bowel preparation scores, colon cancer, colonoscopies, bowel preparation, nurses, split-dose bowel preparation regimen, PrEP solution

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