0:05

Behind. The Night The Surgery

0:08

Podcast Relevant and engaging content

0:10

designed to help you dominate

0:12

the. Welcome

0:22

back to another episode of Clinical

0:24

Challenges and Colorectal Surgery with Doctor

0:26

School and the A Cab Lucas Potions,

0:28

he. To they

0:30

we'll be discussing several cases surrounding the

0:33

management of advance and malignant polyps. But.

0:35

Before we begin, I think it's first

0:37

important to write all the listeners that

0:39

the U S Maltese Society Task Force

0:41

On Colorectal Cancer. With. Representatives from

0:44

multiple G I societies last

0:46

issued cohen asked me surveillance

0:48

recommendations and early twenty twenty.

0:50

The. American Society for Gastrointestinal and Ask It

0:53

being provides guidelines on how to remove

0:55

polyps as well as recommendations for follow

0:57

up. after corn ask be in pipette

0:59

to me. And. These have been included

1:01

in our show Notes for your future use. But.

1:04

It were It really is important. Remember

1:06

that these are only guidelines and the

1:08

frequency of corn ask a beach is

1:10

influenced by many factors, some as simple

1:12

as the pro quality about reparation at

1:14

the time of your scope. And.

1:17

This should be mentioned in every report so

1:19

you would have to remain up to date

1:21

and remembers. There are things like the Boston

1:23

Bell Prep Scored that you really should know.

1:27

Before. We start talking about. Advance Malignant

1:29

Polyps. I think it's worth repeating to

1:31

everybody so that we know in the

1:34

past ten to fifteen years they've lowered

1:36

the screening age from fifty to forty

1:38

five. The. Answer: and you're

1:40

outside. Scores: forty five for average risk

1:42

patients for their first call An Oscar.

1:44

Be. In. Color Guard is a

1:46

store base test and it detects three

1:49

things it picks up on in a

1:51

global. And. Then it also picks

1:53

up on to other separate our

1:55

dna mutations. They are related to

1:57

political rectal cancer. This. is a

1:59

good option for patients who just refuse to

2:01

have a colonoscopy or if they're at a

2:03

poor risk to have a screening colonoscopy or

2:05

they don't have access to a colonoscopy. However,

2:08

keep in mind, somebody comes in

2:10

with rectal bleeding, cologuard's already

2:12

immediately positive because it does detect

2:14

hemoglobin. Cologuard is

2:16

approved for average risk patients, not

2:19

high risk patients, so people with a history

2:21

of polyps or failing history are also not

2:23

candidates for a cologuard. The

2:25

sensitivity for cologuard picking up cancer is

2:28

very high. It's around 92%,

2:30

but detecting advanced adenomas or serrated

2:32

polyps is only 40%, so

2:35

it's also something that you should talk to your

2:37

patients about. I

2:39

think another point to highlight is that

2:42

in patients with no identified risk factors,

2:44

the cumulative lifetime risk of colorectal cancer

2:47

is still very significant at about one

2:49

in 20. And

2:51

colonoscopy is really the only truly

2:54

preventative intervention. Dr. Kavlukas mentioned about

2:56

cologuard and the like, and of

2:58

course they have a role, but

3:01

most of the time they seem

3:03

to be detecting an

3:05

early stage cancer rather than

3:08

a advanced disease. And

3:10

arguably at some of these situations,

3:13

the horse has already bolted, and

3:15

so colonoscopy does prevent us from

3:17

being in that position. Yeah,

3:20

I could not agree more. If patients are on

3:22

the fence, they're really trying to push for colonoscopy

3:24

from the preventive aspect. When we

3:26

had talked about this, even as a group the other

3:28

day, we had mentioned the point

3:31

to reiterate about the increasing

3:33

rate of early onset colorectal

3:35

cancer, especially rectal cancer in

3:37

patients under 50, because oftentimes

3:39

younger people aren't undergoing those

3:41

colonoscopies. However, I think it's

3:43

an important thing to note that younger

3:46

folks will be found to have polyps

3:48

the majority on the left side, so

3:51

they could be picked up on a flexible

3:53

sigmoidoscopy if you can't get the colonoscopy approved

3:55

by insurance, and just

3:58

a side note to mention. Today,

4:00

we're discussing the subset of

4:03

advanced mammalian polyp management without

4:05

getting into the tedious surveillance

4:07

interval recommendations referenced previously. All

4:10

right, so let's talk through a

4:12

few cases. We'll say it's a

4:14

53-year-old female who comes for a

4:17

screening colonoscopy. And in the CECM,

4:19

you find a 25-millimeter cesal polyp

4:21

that's completely resected on block using

4:23

a saline lift. It was

4:25

a cesal polyp, which is why you had the saline lifted.

4:28

And the path demonstrates a

4:30

moderately differentiated adenocarcinoma arising

4:33

within the polyp extending to

4:35

within 0.2 millimeters of

4:37

the cauterized margin. Now, we're telling you

4:39

that because obviously that's important. So

4:42

there is no other evidence of pathologic high

4:44

risk features. So what are the

4:47

next steps to considering these patients? First,

4:50

the term malignant polyp refers

4:52

to a colorectal polyp, including

4:54

flat, sessile, and pedunculated ones,

4:57

with neoplastic invasion of the

4:59

sub-ucosa without extension into the

5:02

muscularis propria. Another

5:04

term for these lesions is submucosally

5:06

invasive polyps. Morphologically,

5:08

pedunculated polyps are classified by

5:10

haggit levels, 0 through 4. And

5:14

the polyp in this scenario is

5:16

sessile, which automatically classifies it as

5:18

a haggit level 4, and

5:20

therefore puts it at high

5:23

risk, an unacceptably high risk

5:25

of lymph node involvement. And

5:28

therefore, I would offer this patient a

5:30

right colectomy. So what

5:32

if the polyp was pedunculated? As

5:35

I alluded to before, haggit level is

5:38

a classification system for depth of cancer

5:40

invasion in the polyps. This

5:42

system is mostly useful for

5:44

pedunculated polyps, and again,

5:46

classified 0 through 4, where

5:49

level 1 notes is plastic

5:51

elements limited to the mucosa. And

5:53

then 1 through 4 have

5:55

submucosal invasion based on their

5:58

invasion into the head. neck and stalk

6:00

of the pedunculated polyp. Level

6:02

1 denotes cancer evasion in

6:05

the submucosa but is limited to the head.

6:08

Level 2 denotes cancer cells reaching into

6:10

the neck and then level 3 invades

6:12

the stalk. Level 4 as

6:15

we said before invades the submucosa below

6:17

the stalk but not into

6:19

the muscularis propria and all knowing

6:21

that non-pedunculated polyps are therefore defined

6:23

as a haggit level 4. Simply

6:26

put, haggit 1 and 2

6:28

means there is likely an adequate margin.

6:31

Level 3 into the stalk typically

6:33

has a deeper margin and therefore

6:35

increases its risk of lived golden

6:38

age and prompts a further discussion

6:40

for surgical resection. Going

6:42

back to the original 20mm

6:45

flat polyp in the right colon, in

6:47

our case of course it was saline

6:49

lifted and removed on block but

6:51

it's important to flag that there are other

6:54

management options. We can of course

6:56

just biopsy it, we can

6:58

lift it and attempt to remove

7:00

it on block as was the

7:03

case or we can leave it

7:05

alone and come back to fight

7:07

another day with either better equipment

7:09

or a better or more advanced

7:11

endoscopist, someone who can perform an

7:13

EMRE or even arrange a combined

7:15

lap assisted endoscopic resection which would

7:17

potentially reduce the mobility of a

7:19

colectomy and anastomosis. Anyhow

7:22

I guess with this patient,

7:24

the patient underwent an uneventful

7:26

right hemicollectomy. The

7:28

CSR polyp was identified, the final

7:30

pathology excluded lymph node involvement as

7:32

such it was considered a stage

7:35

1 colon cancer and

7:37

so what is our surveillance

7:39

for this? The patient should

7:41

have a repeat colonoscopy in one year

7:44

and I like to glamorise it for my

7:46

patients and tell them I'll see them back for

7:48

school on our one year anniversary

7:50

together. So

7:52

Dr. Glendag, do you want to give us

7:55

another case presentation? Of course

7:57

I was referred a patient for a second

7:59

opinion. regarding what was termed

8:01

a superficial rectal cancer that was

8:03

identified in a pedunculine polyp that

8:05

was removed during colonoscopy and the

8:07

patient was absolutely distraught and had

8:10

already been sent referred to a

8:12

medical oncologist who was actually the

8:14

doctor who referred her to me.

8:16

The pathology report read

8:19

minimally invasive adenocarcinoma invading

8:21

into the submucosa with

8:23

intramucosal adenocarcinoma arising within

8:25

a tubular villus adenoma.

8:28

No lymphovascular space invasion was

8:30

seen. There was an

8:33

important comment to the pathology

8:35

report that described stock margin

8:37

focially involved by adenoma in

8:40

well-oriented sections. Now

8:43

this is important because as a specimen

8:45

isn't oriented properly the pathologist really can't

8:47

give you a good report and

8:50

in cases like this I think the

8:52

most important thing to do is to

8:54

calm the patient and get an ad

8:56

mythology read to confirm first that

8:58

the specimen was in fact well

9:00

oriented and that the polyp

9:03

was pedunculated not sessile and

9:05

secondly to make sure that this was

9:07

indeed a minimally invasive cancer. As

9:10

HAGIT is not used by many

9:13

pathologists an actual measurement in millimeters

9:15

of depth of invasion of the

9:17

submucosa is often easiest when describing

9:20

these submucosal cancers and

9:22

measurement of invasive cancer to the

9:24

stock margin. In this case

9:26

there was less than one millimeter

9:29

of submucosal invasion present and

9:31

six millimeters distance from the invasive cancer

9:33

to the margin of the pedunculated poly

9:36

stock and re-review showed

9:38

a tubular villus adenoma with

9:40

high-grade dysplasia and focal areas

9:42

invasion into the superficial and again

9:44

that's less than one millimeter of

9:47

submucosa with desmoplastic stromal response

9:50

the stock margin was negative

9:52

for high-grade dysplasia or

9:54

invasive adenocarcinoma. She was

9:57

presented at the MDT and only

10:00

surveillance recommended. So

10:02

before we move on, I'm going to

10:04

ask another of my junior questions that

10:06

I always admire at Dr. Glandiek with

10:08

some of these cases is

10:11

I commonly get colonoscopy reports

10:13

that just say polyp. So

10:16

if you don't know if it's pedagulated

10:18

or sessile, how would you proceed with

10:20

this case that you're talking about? Well,

10:23

again, the accurate measurement of the

10:25

depth and evasion in malignant polyps

10:27

really requires specific handling of the

10:30

pathology specimens. And this is really

10:32

important because for larger polyps, this

10:34

involves pinning the specimen to a

10:37

stiff material before it's put into

10:39

formal and to maintain its proper

10:42

orientation. And pinning of

10:44

the specimen actually allows the specimen

10:46

to be properly oriented for evaluation

10:48

by the pathologist. Dr.

10:51

Glandiek, can you tell us a little

10:53

bit more about the importance of submucosal

10:55

invasion? Yes. So

10:58

I still see

11:00

the term haggard quite often, although

11:02

I'm in a sort of obviously

11:04

a different country. And

11:07

as I think Hilary mentioned, a

11:09

haggard for by definition is a

11:11

flat polyp. Sorry, a flat

11:13

polyp is by definition a haggard for. So

11:17

having said that, I think the

11:19

challenge with submucosal evasion is of

11:21

course, knowing how

11:23

deep is it, because unless one

11:26

has muscle within

11:28

the biopsy, in my mind,

11:30

it's very difficult to measure what is

11:32

one-third, what is two-thirds, what is three-thirds.

11:35

And I do think what Dr. Glandiek mentioned about

11:38

kind of identifying what

11:40

is an invasion of less than

11:42

one millimeter and that being called

11:44

superficial submucosal invasion rather than something

11:47

deeper. Being deep submucosal invasion is

11:49

very useful. And this

11:51

then correlates to risk of metastases of

11:53

course. So something which is less than

11:55

one millimeter has about

11:57

a zero to four percent risk of. sort

12:00

of an advanced cancer whereas something

12:02

which has a depth of greater

12:04

than one millimeter is associated

12:06

with a risk of residual disease in the

12:08

bowel or lymph nodes at about 10 to

12:11

almost 20 percent and

12:13

so therefore is an indication for

12:15

surgical resection in far greater cohort

12:18

of patients. And I think

12:20

here it really is important to know where

12:22

pathology reports are coming for. There

12:24

are some really very good quality

12:26

pathology labs and there are

12:29

some pathology labs that are

12:31

for example run by in

12:33

NLS by large GI group

12:35

practices where the quality of the

12:37

reads may not be as known a

12:39

quantity. It's never wrong to get a

12:41

second opinion. I can't

12:43

tell you how often in my career this

12:46

has resulted in really a big change in

12:48

the diagnosis. This is especially

12:50

true if you're receiving more referrals

12:52

from areas with smaller populations and

12:55

resources. It's really important to

12:57

know an expert either at the

12:59

institution where you're working or

13:01

where you did your training at where you can

13:03

send slides for review. Okay

13:06

so let's move on to our third case of the

13:08

day. Dr. Bulczycki

13:10

you have an obese 60

13:12

year old male who's a

13:14

smoker who's underwent his first ever

13:16

screening colonoscopy and was found to have a

13:18

15 millimeter sessile serrated

13:21

adenoma that was biopsied but

13:23

not removed entirely from the

13:26

CECM. He otherwise was noted to

13:28

have two 8 millimeter tubular

13:30

adenomas removed by cold snare

13:32

in the descending colon. How

13:35

do you prepare to call this patient to

13:37

discuss his pathology results

13:39

and what are your recommendations? So

13:44

patients with SSAs

13:47

are at an increased risk of future

13:49

colorectal neoplasia and

13:52

this may include both advanced polyps and

13:54

cancer. Reasonable

13:56

benchmarks for detection

13:58

of such polyps is That marketing

14:01

different. Certain underscore big

14:03

techniques such as Crime and Oscar

14:05

be narrow band imaging Water immersion. Wide

14:07

angle viewing and may help with

14:09

detection of light bulbs. And

14:11

set of more imaging techniques like Underwood

14:13

Apollo deck to me. And

14:16

booze and of more piecemeal receptions of

14:18

these bullets are helpful tools for and

14:20

Us contests. As. Doctor Gland Egg

14:23

said have labored on the point

14:25

of both ensuring that the polyp

14:27

as well preserved and I'll say

14:29

well analyze. This is incredibly important.

14:32

Say. You know what? I prepared

14:34

to talk to the pace and I

14:36

discuss old days I also but I

14:38

said move have a far greater threshold

14:40

of repeating endoscopy on someone. With.

14:42

A sled polyps because I do worry

14:44

that we miss them because our pattern

14:46

of for the weekend is paula to

14:48

less and I'll said I'm very careful

14:51

to analyze what the quality of the

14:53

bow prep was because that is an

14:55

elephant of the room and when it

14:57

comes to add determining how frequently was

14:59

go pick. The

15:01

i think it's it is interesting. They've recently

15:03

changed. The nomenclature to be ss

15:05

else now, which is is that

15:07

South's rated lesion because they're not

15:09

necessarily polyps adaptable. Shinskie Talk about

15:11

they have. Very. Irregular margins

15:14

I've I've biopsied a few things just

15:16

to they looked weird or the granular

15:18

pattern of the elo sequel Valve just

15:20

didn't look right to mean it came

15:22

back as assess also rated. Li.

15:24

Node change And so I think that. They.

15:26

Sing. Pet weekly they are

15:29

tempted to undergo surveillance at intervals similar

15:31

to what's recommended for the conventional had

15:33

no less. But the A D A

15:35

also has. Kind. Of shorten the guideline where

15:37

if you have to be or add know because. They'll.

15:40

say seventy ten years but if he

15:42

obsess else rated at lesions they'll say

15:44

five to ten years because eight years

15:47

they don't go the through the typical

15:49

vogelstein pathway of add no matter carcinoma

15:51

and they kind of evolved through the

15:53

cpg methylation pathway and ml h one

15:56

mutation to their carcinoma nobody's really studied

15:58

how long this takes So

16:00

I agree with Dr. Balsinski, I kind

16:02

of would keep them at a little

16:04

bit higher level of a large just

16:06

because they're difficult to see, they don't

16:08

have distinct borders, they have a different

16:11

pathway to carcinoma than other adenomas that

16:13

we have historically studied. The

16:15

patients with sesalsal-slaureate lesions may be

16:17

able to lower their risk factors

16:20

by limiting

16:22

their smoking and alcohol use, high-fat

16:25

diets, and says that aspirin

16:27

appeared to be protective agents in some

16:29

correlational studies though there's been no actual

16:31

scientific studies showing this. We

16:34

have seen in throughout the literature that

16:36

endoscopists that are better

16:39

at removing the right-sided sesal-slaureate

16:41

lesions do have lower colorectal

16:43

cancer incidences in those studies

16:46

and there's a recommendation by the AGA

16:48

that the second look, whether that be

16:50

forward view or retroflection, should be made

16:52

in the right colon to help increase

16:55

the detection since these are so common

16:57

on the right side. This is why

16:59

many endoscopists will only scope with pediatric

17:01

scopes. Hey, behind the knife

17:03

listeners, it's Kevin here. Do

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BTK50. Now back to the show.

18:12

And Dr. Volcinski, I know you had

18:14

brought to up earlier in an earlier

18:16

discussion about other ways to potentially increase

18:19

right-sided detection of polyps that aren't necessarily

18:21

commented on any guidelines. Do you want

18:23

to tell us a little bit about

18:26

your thoughts there? Yeah,

18:29

a few interesting points. I

18:31

actually, first of all, really

18:33

like pediatric scopes, but

18:35

what I've noticed, and this is a

18:37

change in culture, in Australia, people

18:39

are typically a lot more heavily sedated.

18:41

And so adult scopes are preferred because

18:43

I think it is easier to scope

18:46

with an adult scope, but it causes

18:48

patients to have more discomfort. And with

18:50

an adult scope, the risk, I think,

18:52

of retroflexing in the sebum, at

18:55

least anecdotally, is greater. And

18:58

so I am reluctant to do

19:00

that personally, but I think multiple

19:03

intubations of the right colon are

19:05

very important to Sandy's point. Now,

19:08

I guess I sort of think

19:11

that it's important to recalibrate one's vision

19:13

for hyperplastic polyps. And

19:15

we've all been taught that classically they

19:17

hide behind the mucus gap. But also,

19:20

I think all

19:22

of us have done colonoscopies in a

19:24

short succession after someone else, and they've found

19:26

fairly large flat polyps. And it's hard for

19:28

me to imagine that those polyps grow that

19:30

rapidly, but rather I think they have been

19:33

probably missed because they don't follow the visual

19:35

pattern that we look for. Now,

19:41

interestingly, with the rapid gains

19:43

in AI, I think

19:46

it's a very interesting field to

19:48

see how technology may augment polyp

19:50

detection, and whether, even if

19:52

that does so, whether that translates to any

19:54

real world benefits. In light

19:57

of the scope, hospitals where I scope at the

19:59

moment, we the hospital has

20:01

purchased this ASM and so

20:03

I do turn it on when I do

20:05

colonoscopies and I personally feel it's kind of

20:07

like maybe having a role

20:10

monitor in a classroom looking behind me to

20:12

make sure that I keep focus and I

20:14

don't copy anyone else's work. So

20:16

I'm not certain if the polyp

20:19

guide itself helps or whether it's

20:21

a Hawthorne effect and I do

20:23

actively look further and more actively.

20:26

The other thing that I'd like to

20:28

say which I have adopted is a

20:30

paper which has been published by James

20:32

Church about 10 years ago in DCR

20:34

called Keeping the Seachem Clean and he

20:38

advocates giving emodium one hour after

20:40

the last bowel movement in an

20:42

attempt to prevent bile leaking into

20:44

the right colon and making it

20:47

a lot harder to visualize that

20:49

area. And so

20:51

particularly for patients who I scope

20:53

in the afternoon, I do prescribe

20:55

emodium and I

20:57

think it helps me. Perhaps this is

21:00

a role for some more research within

21:02

the now AI space. In

21:04

the advent of AI, do you feel

21:06

it, are you able to see the parameters that

21:08

the AI program picks up? Like does it pick

21:11

up the same as or more follow ups than

21:13

you would and the second question is do you

21:15

feel like in the future it might

21:18

be do your bowel prep at home swallow

21:20

this capsule and we'll see if this capsule can find polyps

21:22

before we have to sit each of you and put an

21:24

IV in you and make you take the day off at

21:26

work? Very

21:29

interesting questions. Again,

21:33

I'm not an expert at AI. I

21:35

love a stick shift

21:37

car and an analog watch

21:40

so it doesn't come naturally

21:42

to me. But what I've

21:44

noticed is when you do scope, there's a

21:46

target sign that appears and you can make

21:48

it more or less sensitive. But I do

21:50

find that it's quite a lot of noise

21:53

and the polyps that we

21:55

agree upon I tend to see anyway

21:57

and the polyps that the AI picks

21:59

up. versus me, I'm

22:02

not sure the significance of that. There is a

22:04

lot of three millimeter little things and whether that's

22:06

a little bit of debris or not, I

22:09

don't know, but I do think it

22:11

helps you slow down and look more

22:13

actively. And that's probably its biggest role

22:15

at present. Your concept

22:17

of a pill cam type

22:20

idea is fantastic and

22:22

I do believe there are some colonic

22:24

pill cams now, but of

22:26

course, I think they're up against a very

22:28

proficient tool in a colonoscopy and the limiting

22:30

factor, of course, is you take the prep,

22:33

you don't get an intervention out of it, so you still

22:35

have to then take the prep again if there's a problem,

22:38

which is hard to sell to some patients. Yeah,

22:41

I agree. In regards to

22:43

keeping the secant clean, in

22:45

Dr. Church's paper, he used two tablets, so

22:48

four milligrams of the sodium one hour after

22:50

he completed the prep, is that your standard

22:52

as well? Yeah, I'm

22:54

openly biased to adopting

22:56

a lot of his ideas. I was

22:59

fortunate enough to train under him and

23:01

so a lot of what I do

23:03

has been influenced by him. Yeah,

23:06

I mean, I read the paper, it was

23:08

randomized, it was prospective and there was pretty

23:11

good results of actually having better detection

23:13

in the right colon after bird, so

23:15

I'm kind of biased into maybe adopting

23:17

the practice tool. But, yes, yes, yes,

23:20

okay. The

23:23

challenge is it was one endoscopist and

23:26

so I think there is a question

23:28

of how translatable it would

23:30

be to both

23:32

other institutions and other practitioners

23:35

and also the endoscopist himself

23:37

has a incredible experience in

23:39

endoscopy, so I think

23:41

his eye of being calibrated to

23:44

flat polyps would be far ahead of

23:46

mine. All right, well, let's move

23:48

on to our fourth and last case. Dr.

23:51

Kabilibgis, you have a 45-year-old male who

23:54

you're performing a first-time screening colonoscopy

23:56

for and you find a 35 millimeter,

23:58

some. my pedunculated

24:01

mid-rectal polyp. What

24:03

are your thoughts and next steps in addressing

24:05

this lesion? So the first

24:08

thing that is really important is to

24:10

recognize that rectal cancer is not the

24:12

same as colon cancer. They're treated

24:14

differently. The importance of staging up front

24:16

is every bit as important, if not

24:19

more important, than colon cancer. Certainly we

24:21

always wanna know if a patient

24:23

has metastatic disease. But for

24:25

colon cancer, the lymph nodes and

24:27

positive lymph nodes that may appear

24:29

on the CT scan don't necessarily

24:32

change your surgical treatment, whereas rectal

24:34

cancer most certainly needs in this

24:36

day and age usually indicates total

24:38

neoadjuvant treatment. So the first thing

24:40

that I do when I look at it is how

24:42

much do I think that this may be a cancer

24:44

or not. A gross

24:46

characteristics of malignancy are obvious

24:48

things like depression, ulcerations. If

24:51

I try to go to a resected or

24:53

saline injected, if it won't lift, meaning that

24:55

it may be invasive to the underlying layers.

24:58

That is something that is a big warning sign

25:00

to tell me to sort of get away. There's

25:03

also pit patterns. Kudo explained in

25:06

his paper over several

25:08

different reports that there's five

25:11

levels of pit patterns,

25:13

level four and five really

25:15

irregular and oftentimes it's

25:17

just the surface of the polyp and how

25:19

it looks can kick you off that the

25:22

irregularity of the glands on the surface may

25:24

indicate malignancy. There's no other

25:26

endoscopic signs that can tell you really how

25:28

invasive it is. Obviously that's at the bottom

25:30

of the polyp but the

25:33

things that do pretend a higher

25:35

risk of superficial invasion into the

25:37

submucosa are typically size over two

25:39

centimeters are non granular

25:41

lateral spreading lesions. Some of these

25:44

lesions that these features should be

25:46

considered either for end block endoscopic

25:48

resection. This may obviously optimize the

25:50

pathologic assessment of any lesion if

25:52

you need to do it full

25:54

thickness versus whether or not, and Dr.

25:56

Glandy I'm sure I will talk a little bit more

25:58

about, you know. if you're able to palpate

26:01

it and in general how this feels.

26:03

So how does everyone do their saline lift since

26:06

it's been mentioned? Do you have any tips or

26:08

tricks for the listeners? I mean, I

26:10

think it's really important to always start in a

26:12

normal area when you do your

26:14

saline lift. Okay. And

26:17

then Dr. Kablugis has taught me as well

26:20

to maybe start more proximal to the

26:22

polyp and inject it there to bring

26:24

the polyp towards you rather than push

26:27

it away. Dr. Kablugis, do

26:29

you have any tips or tricks? Not

26:32

really. I sometimes find that saline lift

26:34

absorbs quite quickly and so I do

26:36

want to make sure that the equipment

26:38

I need to remove the polyp is

26:41

in the room. Nothing drives

26:43

me more crazy than sort of preparing

26:45

something and then realizing that I don't

26:47

have the right snare. So

26:49

it's a practical thing, but that's

26:51

probably something which is very important.

26:54

When I started scoping, we used to

26:56

use gel effusion, which is a colloid solution.

26:58

I don't really use it anymore. It's

27:02

actually quite hard to get in the hospital.

27:04

I don't think it's stocked as readily as

27:06

it used to be, but that may be

27:08

an option because obviously the colloid would not

27:10

absorb as quickly. I mean,

27:12

the colloid solutions that are available, I think,

27:15

I honestly don't think they

27:17

make it any easier than just using

27:19

saline. Yeah. And then

27:21

it also might be worthwhile for some

27:23

of the younger listeners to know

27:26

that, there's cold versus hot

27:28

snare. Cold usually is less

27:31

likely to bleed and to consider if you're

27:33

taking the polyp from the right side of

27:35

the colloid might be a little thinner versus

27:37

the left or the rectum, which is extra

27:40

peritoneal and that part

27:42

of the AGAs best practices that

27:44

use of cold snare for all

27:46

cesal polyps, three to nine milliliters.

27:49

So, okay, moving along,

27:52

Dr. Bolshinsky, what are your thoughts

27:54

on tattooing this area of the

27:56

mid-rectum? Yeah,

27:59

it's an- An interesting question, thank you. So

28:01

obviously tattooing is very useful in

28:04

confirming the location of the cancer

28:07

in general and this would enable precise

28:09

surgical oxygen, particularly MIS. However,

28:13

both the cecum and the rectum

28:15

I believe are exceptions to this

28:18

because they can both be confidently

28:20

and accurately identified without needing tattoo

28:22

both endoscopically and then minimally

28:25

and evasively for surgery. So

28:27

for polyps identified outside the rectum, I

28:29

guess the, I think it

28:32

significantly improves things and I think it's

28:34

important to know that the technique of

28:36

tattooing is important and that you want

28:38

to be injecting in an oblique manner

28:40

and I think Dr. Hyman's

28:42

recommendations were a four

28:44

quadrant circumferential tattooing technique

28:46

to improve circumferential visualization

28:49

and that technique involves about

28:51

0.2 to 0.5 mils of

28:53

Indian ink raised in a

28:55

bleb about one centimeter distal

28:57

to the tumor or lesion.

29:00

Now of course there are however downsides

29:02

of tattooing and this brings us back

29:04

to the question about the tattooing in

29:06

the mid-rectum and so I think

29:08

the plane of dissection may be obscured. If

29:11

the son's bureal injection and spillage of the

29:13

dye occurs, it may also

29:15

cause submucosal fibrosis and therefore a delayed

29:17

lift would be far more challenging. And

29:20

also if you are to then

29:22

perform a TME, there is a

29:24

query whether the tattoo would cause

29:27

inflammation in the mid-rectum and also

29:29

cause that dissection to be more

29:31

challenging. So it's

29:33

certainly not a free intervention. There

29:35

are costs. No comment? I

29:38

typically, I think that in the advent

29:40

of watch and

29:43

wait, depending on where

29:45

the, certainly you would think that it should

29:47

be pretty easy to be able to at

29:49

least see a scar that you're going to

29:51

surveillance. In certain cases

29:54

I think that it may be important to

29:56

put the tiniest bit of ink

29:58

just so that you're certain. which

30:00

wall it's on or if it's, especially if

30:02

it's somewhere in the second

30:04

or third rectal valve area where you're not necessarily

30:06

going to be able to feel the scar either.

30:09

I've had, you know, at least

30:11

three cases now where I have scoped

30:13

them after they got their chemo radiation

30:15

and was like, you know, wow,

30:17

thank goodness there was a tattoo there because you

30:20

really could not tell where the tumor was. It

30:22

might just be useful for photographic

30:25

surveillance and documentation as you follow

30:27

it. And I mean,

30:29

I agree. I don't think that it's

30:32

necessarily, you know, when I do my L.A.R.s,

30:35

they don't say, okay, there's the tattoo. I see

30:37

it, thank goodness. I just need to get a

30:39

distal large. And I just put a very tiny

30:41

bit around the cancer. If I think that watch

30:44

and wait is hopefully an option that this patient

30:46

is going to go after it. Also,

30:48

I think if you have a rectal polyp

30:51

that looks suspicious, particularly the

30:53

undunculated polyps where once you excise

30:55

it, you might not be able

30:57

to identify it anymore. If

31:00

you think they're evitinididig or resectin or

31:02

do a local excision afterwards, I

31:05

think they're tattooing the site of the

31:07

excision also within a small amount

31:09

of tattoo dye, I think

31:11

is useful. And

31:13

regardless of where tattoos are placed, to

31:16

document exactly what your

31:19

thought process was, where you put the

31:21

tattoo relative to the lesion,

31:23

it's always helpful for you or whoever

31:25

the next person is who's going to

31:27

help this patient, which is not always

31:29

the case. So it's always

31:31

good to have a reminder. Yeah,

31:34

I can't agree more with this, because

31:37

you may be surveying this patient for the next 20 years. And

31:41

reproducibility is incredibly important. It's

31:43

almost I think this component

31:46

of surgery is that playing chess. You

31:49

want to think four moves ahead of what

31:51

you're going to be faced with. And if

31:53

you tattoo each patient differently, come

31:56

their fifth or tenth scope, you'll have

31:58

no idea what was the original. idea

32:00

that you had and good luck finding the notes

32:02

at that point. Sure. I

32:05

think it's also, I'm a little bit leery,

32:07

I don't disagree with you. The CECM has

32:10

definite landmarks that should make you

32:12

aware that you're there. However

32:14

I have seen the CECM and the hepatic

32:16

plexia confused time and time again. So if

32:19

I oftentimes will get a polyp

32:21

that is binic sized that has some

32:23

sort of carcinoma at the margin, I

32:26

will scope them the day before I operate on

32:28

them to make sure that I see sort of

32:30

agree that they were at the CECM and not

32:32

the hepatic plexia. I

32:34

agree with you and that brings up a

32:37

different debate whether one

32:39

should trust anyone else's scope entirely

32:41

before you operate on them. Because

32:43

I think if I scope someone

32:45

and identify the CECM, I'm confident that that's the

32:47

CECM. And if someone tells me that they

32:50

identified the CECM, I'm sadly far less

32:52

confident. Yes, but then when you get it.

32:55

And the case that I described

32:57

earlier was tattooed and the entire

33:00

upper half of the rectum was blue. So

33:03

a bit of anti-hell tattooing.

33:06

But I guess, I mean, these are real world things

33:08

that happen. I mean, as surgeons

33:10

who I think are largely the

33:12

listening audience of this podcast, I

33:14

mean, we're out there most

33:17

days doing colonic resections and doing colonoscopies,

33:19

you know, 10 to 20% of that

33:21

time. So I

33:24

think it's a lot of, you know, you don't

33:26

want to subject patients to ongoing repeat colonoscopies and

33:28

a lot of these things are kind of out

33:30

of your hands. But sort of figuring out how

33:33

you're going to heal with it is something that

33:35

you will adapt to as you go through your

33:37

practice and you learn who kind of refers you

33:40

lesions and how they've been treating you. Well,

33:43

I think today's been a really great discussion

33:46

and we've all learned a little something new.

33:49

But we've got to wrap it up with our five

33:51

quick hits of the day. The

33:53

first being, remember that the screening age

33:55

for first colonoscopy for average risk patients

33:57

is 45 years old. then

34:00

Colaguard is another option for those

34:02

special cases that we mentioned. A

34:05

malignant polyp is defined as neoplastic

34:07

invasion of the submucosa without extension

34:10

into the muscular arthrobium. Cessal

34:13

serrated lesions progress to carcinoma

34:15

along the CPD methylation pathway

34:17

and carry malignant potential. Large

34:21

polyps should be orientated on a

34:23

rigid surface before sending to pathology

34:25

and formalin. And

34:27

always consider pathology re-review prior

34:29

to proceeding with resection. So

34:33

thank you all for your attention and

34:35

until next time, dominate

34:37

the day. Be sure

34:39

to check out our website at www.behindtheknife.org for

34:41

more great content. You can also follow us

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34:56

We do not diagnose, treat or offer patient

34:58

specific advice. Thank you for listening. Until

35:01

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