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Um So we should be live now. So good evening to those that have joined us so far. Um For those of you that were here last week, then I would have already introduced my, myself. I'm Katie at the Endoscopy Rep for Dukes Club. Um And tonight, we've got two speakers joining us. We're really lucky. Um So we've got Mr Amon Hadie who's a consultant colorectal surgeon at King's College Hospital in London. Um And he's also an interventional endoscopist. Um And the course convener of King's live that many of you might have heard of. And we're also joined by his colleague, Mr Andrew Emmanuel, who's also a consultant colorectal surgeon and interventional des interventional endoscopist at King's. Um So thank you both for joining us tonight. We're really lucky to have you both um some real experts in endoscopy. Um So, just to recap tonight, we're going to be going through polyp assessment and optical diagnosis. Um I'm sure that Mr had and Mr Emmanuel will mention this later, but um they do run Kings live in London. Um That's a really excellent endoscopy event um that is free for trainees. I've been for the last few years and I'd highly recommend it. Um But without further ado, I'll pass you over to Mr um had you and Mr Emmanuel to get the session started. Um similar to last week, we, we are happy to take some questions as we go along, but we've designed it to be quite interactive anyway. But if you do have questions, then please do post them in the chat. Thank you very much, Katie. I'm really delighted to, to join here with Andrew and in the format of the evening, um today is what we'll do is we're going to start off with a quiz and there will be a poll system that you can actually answer some of the questions based on endoscopic diagnosis. These are just seven questions that we put together and then we'll break into a elect on end diagnosis and assessment and then repeat that quiz to see how you've done both before and after the lecture with some explanation. And then of course, we'll have time for taking questions and discussing some cases while an MDT approach so very much looking forward to it. So, thanks very much for inviting Andrea and myself. And what we'll do is we'll start first with the quiz. I'm just going to share my screen to do that. So, um so the first question is related to these three images that you can see uh image 12 and three and there are three lesions that we've identified for you. Uh And what is the appropriate Paris classification for these three lesions? Uh You can see there's either ABC or D. Uh So I'm not gonna go through those, but essentially if you think it's a, then you will think that one is one, s two, is two C and then three is two A plus depression, et cetera. So you can either choose ABC or D. So take your time and have a look at these questions. We'll give you 10 or 15 seconds to look at that and think of your answer. And then once you've done that, let's put the pole up Katie uh to see and allow them the chance to answer those questions. How are people doing? People answering the questions, Katie uh not had that many responses so far. OK. Yeah, we're getting a few more now. Good. Yeah. Do have a go guy doesn't matter. Um what you think it is. It will be interesting to see how you got on before and after the lecture. I thought this was quite difficult actually myself and it's not the easiest actually. It's a bit of a, it's tricky that uh I think often the more you know that you, you try and be very precise about your parents classification. So if we stop it there, we've had about 20 people reply so far. So we have on the 25. So we've got 36% of people have said a 16% of people have said B 40% have said C and 8% have said D OK. So C is the most popular choice. OK. Let's remember that Katie for next time, I'm going to move on to the next question now. So second question is related to these are magnifying endoscopy images. This is 100 and 3100 and 35 times zoom on magnifying endoscopy of the surface pattern of polyps. You'll see the blue images like in one and four are with indigo carmine and magnification and the images which are more purple, which are two and three are related to magnifying images with crystal violet staining. So, in your opinion, um what do you think is the Kudo pit pattern for these different surface characteristics for the polyp? So once again, it's either ABC or D. Uh So for example, if you think it's a, then you think one is type 42 is type 23, is five I and four is type 3 L, et cetera. So have a look at this. We'll give you 10 or 15 seconds and then take a chance and then we'll put the pole up in a short while. OK. So I'm going to put the pole up now and give you a bit of time to look at that and you think we've got good responses, Katie will um uh we'll move to the next, how are we doing on the poll? So we've got about 20 responses. So we'll close it there. Yeah. So we've got 34% said a 46% said B 11% said C and 7% SD. OK. So uh popular on the A and B ones or the popular ones. OK. We'll move on to the next. So, question three is this lesion was found in the ascending colon in a 55 year old lady. Uh What do you think is the endoscopic diagnosis for this lesion? And what would be the next step? Would it be a, do you think this is a hyperplastic polyp and you leave this inside you? B is this invasive cancer? And would you have surgery? C is this a tubular adenoma? And would you go on to perform a polypectomy or D? Is this ac ulcerated lesion? And you would go on to do a polypectomy to give you 10 seconds or so to have a look at those images and those options and then we can put the pole up and give you 15 seconds to answer the poll and well, then move on. OK. How are we doing, Katie? Yeah. So I have 25 responses. So we'll close it there. So we had 3% said hyperplastic, 3% said cancer, 38% said adenoma, 54% said SSL. OK. So C and D were more popular for that question and we'll move on to the next. So, question four is this is a patient that underwent a colonoscopy for a change in bowel habit and abdominal pain. And this was the following lesion that you can see that was identified, the bowel preparation wasn't very good. Um But the, this is uh the lesion that you can see. Um Do you think that this is a, an LST G homogeneous type? And would you go on to perform an er piecemeal? Do you think this is an LST G mixed nodular type with a dominant nodule? And would you go on to perform an ESD or refer appropriately? Uh And C is this LST G mixed nodular and try and do an er on block or is this LST G homogeneous type? And would you do ESD en block? So I give you 10 or 15 seconds to look at those images and those options, ABC or D and we can put the pole up Katie. OK. How are we getting on? Yeah. So a lot of experts here tonight. So we've got no one said a 83% said B 10% said C and 6% said D OK. So we've got predominantly B and some going to see OK, fine. So we'll move on to the next one. Question five is, what is the J net diagnosis? What was the Janet which is the M BI, the Japanese er expert classification on that magnifying image? What do you think the Jin Act vascular pattern is, is it genet type one, which is A two A, which is B or C is two B or do you think this is Janet type three? And that's D so have a look at that. Um And think about the gene classification and in terms of the gene classification for this particular question, you would be looking for the most advanced one that you can see and let's put the pole up Katie. Yeah, so 20 responses so far. So we'll close it there. So we have 3% said type 1 41% said type two A 37 said two B and 17 said type three. OK. So we've got a mix of responses there, predominantly B and C but at least 1/5 of them saying D as well. OK. A couple more questions. Uh Last one, this is more simple in terms of your choices, either A or B here. So you can see this image of a polyp that you can see. There's a magnifying image of one particular area of interest. Uh This is actually a small 20 millimeter lesion that was seen in the colon. Uh And on the magnifying image centrally, you can see the magnifying vascular pattern, the J A pattern. And the image on the right is on crystal violet staining and it's a magnifying endoscopy showing the pit pattern. So looking at these images, do you think that this is a, it's an adenoma or a superficial cancer and patients should undergo endoscopic resection or B. Do you think this is a deep cancer? T one cancer and patient should have biopsy, tattooing and offered surgery. So the question is either A or B simple choices here. You put the poles up, please, Katie. Yeah. Where we going? Just give it a couple more seconds. So 60% said a 40% said B OK. So it's a mix here really, isn't it? Are people undecided about what that is? And final question is just related to factors that are least least recognized as contributing to scarring and fibrosis of the polyp. So which of the following factors are least recognized to contributing to scarring or fibrosis of the polyp? Is it a sequel? Cyto Polyp B mechanical trauma, the previous intervention such as biopsy or previous E Mr or Polypectomy D underlying colitis or E LST G homogeneous type. So which of the following factors is least recognized to contributing to fibrosis or scarring? So, have a think about that and then we can just put the poles up, please, Katie. OK. So we'll close it there last few answers. So we've got 39% have said sequel, 6% have said trauma. 20% have said previous intervention, 11 colitis and 25% LS TG. OK. So there's a mix of answers there. So hopefully, this will become a little bit more evident when we do the lectures. OK. Thank you very much. That's the end of the quiz. Uh what I'm going to do is just stop sharing my screen. Um And we can then go on to the next stage. It gives me a great pleasure now to actually invite Andrew uh Emmanuel, who's, and I think many of you should chat to Mr Emmanuel uh when you have the chance to see him or contact him because um Andrew spent um nearly six or seven years at King's as a fellow doing a phd in Advanced Endoscopy Fellowship. Uh And now really is an expert in endoscopic diagnosis and has been a consultant Kings for the last few years uh working alongside me as my colleague and is an expert in endoscopic diagnosis of colorectal lesions and also in management of these lesions in particular for ESD. So he has huge experience and uh you may be interested you going to follow in um footsteps in terms of training, uh what his path has been like. So it's a real honor for Andrew to join us. I'm delighted that you're giving this lecture. I very much look forward to, to hearing your thoughts on optical diagnosis. Andrew of colorectal lesions. Thanks very much for the kind introduction to me and thanks Katie for having us. It's a real pleasure to be talking to surgeons about this, to be honest, because we really believe it does belong in the realm of surgery. Optical diagnosis leads to endoscopic resection and ESD is very much a surgical procedure. So it's great to be talking to an audience of surgeons. So, optical diagnosis we hope for during this to go through and hopefully give you an easy way of remembering standardized classifications of polyps. Primarily they're standardized morphology, which is very variably reported. In fact, in our experience, it it's very inconsistently reported. Also go through what some of the associated morphological features of polyps are that are often also not reported on, but are really important in trying to get an idea of what the diagnosis is. Talk about the surface characteristics, the pit pattern, the vascular pattern, uh and what we use to assess those and just go through how to put it all together and how to actually make a standardized assessment of a colorectal lesion that you can, you can repeat every time and really results in a good standardized report that has all the information you need. And it's easy to remember and it really leads to much better management down the line as we'll see in some of the examples that we give, we're not gonna talk about anything technologically advanced because it's not really necessary. So what what we wanted to focus on today is just giving a good diagnosis using everything available in standard endoscopy units around the country. There are some other adjuncts you can use in specialist practice. But 99% of the time you can arrive at a diagnosis with equipment, we already have. So what's the point of it? I mean, do we really need all these things? We see these pictures and these complicated things and all these numbers and assessments and horrible descriptions and they seem outside the sort of standard realm of colorectal training. But they're important obviously to just make a diagnosis. You see all these types of descriptions. I think we've all probably used them ourselves. I mean, this isn't something made up. I just found these by looking at recent referrals and they pop up all the time. These things like flat polyp from like villous or carpet like and what do they really mean? And some of my favorite is neoplastic or a polyp without neoplasia. I don't know what people mean by that. Do they mean there's no cancer or do they mean there's no dysplasia? I mean, neoplastic just means abnormal growth that's driven by abnormal biological markers. So it's anything from an abnormal crypt through to an adenoma, through to a cancer really. Uh So it can be very confusing and mitotic lesions used a lot as well. I mean, mitosis doesn't necessarily mean even neoplasia, let alone cancer. Uh So it's important that we know what we're talking about. So we can tell the patient what they actually have. Uh You can decide if you can treat this at the time or does it need something else later? If you need to take samples, you can make me, you can take meaningful samples or you can avoid taking unnecessary samples. There's a question about uh fibrosis and scarring in the quiz. Well, one of the most common problems we have is just in judicious biopsy, loads of them sometimes repeat biopsies. Sometimes people take what they call snare biopsies because they think taking a big chunk out of it will be useful. That's extremely dangerous really because it causes profound fibrosis. And there's good evidence that that makes endoscopic resection much more difficult and more dangerous. You can arrange timely investigation straight away. You can decide at the time, what the next course of management is and what the urgency is. And you can tell the patient about that and you can do this all right at the time of endoscopy. And more importantly, you can avoid all these unnecessary additional procedures. I think we must have all sat in MDMS where patients have already come with, you know, two or three repeated endoscopies for more biopsies because nobody's sure what's going on and the biopsies show something. But the endoscopist thought something else we can avoid all of this and these unnecessary delays and the uncertainty that that patients go through. And most importantly, you can just be a doctor, which is all about making a diagnosis and advising appropriate treatment. So how do we do that? Well, the first thing is morphology because that's probably the single most important factor in an assessment. You can do this in a few seconds almost. And a lot of the time it gives you almost all the information you need uh to make a diagnosis, uh depending on the lesion in question. Sometimes it can give you everything you need to make the diagnosis. And what we use is the Paris and the Japanese classifications. And this is what the Paris, I'm sure we've all seen this and we probably use it a bit. I'm not sure if everyone's using it consistently. Again, our experience, it's definitely not used consistent and we find it only used in a minority of reports. And when it is, it's not always correct. And part of the reason is look at that, it's really quite confusing. There's all these numbers and dashes and different letters with it, funny looking pictures and it can be quite hard to make it or tell of what's going on, but it doesn't need to be so difficult because firstly, you've got really just two separate groups, you've either got protruded or not protruded. And by the way you see the zero dash something and that also makes it more complicated looking. That's probably why it's not used consistently just as an exercise. I bet if you go and ask expert endoscopist in your hospitals, particularly some of the gastroenterologists who might be responsible for your training, what does the Xero stand for? I'm sure nine out of 10 people probably won't even know all it is is just the old Japanese classification and they had 1 to 4 of deep and invasive cancers and Xero just means superficial. In other words, it's either in the mucosa or it's a submucosal cancer in the superficial layer. So you can really just discount it and let it go. So it's not too confusing and then you've just got type one or two. So type one, if it's protruding into the lumen, it's type one. if it's not, and it's closer to the surface, it's type two. So if it's type one, it either looks like a tree and it's got a trunk and it's pedunculated or it looks like it's stuck on, like it's a golf ball cut in half and, and stuck onto the mucosa and it's set up and that's all it is. You have the subpedunculated category, which is pretty much SES R. So if it looks anything like sr it's either one S or one sp and it really doesn't matter because to my mind, they are both biologically and in terms of cancer risk, the same type of lesion. So if it looks like a tree with a proper stalk, it's one P, if it looks like anything else, it's probably a one S or a one sp, including some of these with a really short thick stalk, they're probably one SPS. You might have to, who cares, you know about that is one S or, or one P. Well, it is important because you send it to the pathologist and some of these have got cancer in them and there's a completely different staging for them. And under the microscope, it's actually quite hard to tell what's pedunculated and what's not in some cases unless you've got a really huge stalk. So if you call something pedunculated and in fact, it's one s or one sp and there's a cancer, they'll give it a Haggett classification because you told them it was pedunculated. Uh Whereas in fact, you need the Kuchi classification and with the Haggar classification, anything up to level three in the stalk here has almost no risk at all of lymph node metastases. But if in fact, this is not a pedunculated lesion and it's acr lesion, then that is really deep submucosal invasion. And although we don't really think that's a significant risk factor anymore. A lot of MDT S still do and you can subject the patient to unnecessary surgery based on just a very simple misclassification. It's exactly like any other diagnosis. You need to tell the pathologist what they're looking at. Uh otherwise they can't be sure and it can have quite significant consequences. So it's either protruding into the lumen or it's not. And if it's not, it's closer to the surface, then it's a type, some sort of type two lesion and you have these flat elevated ones, there's no, it's not necessary to get into any, any semantics about how high is it off the off the surface, all you have to look at is, is it pretty much wider than it is higher? A man is probably a type two. And if it just looks like that, it's two way. If on the other hand, it looks like some sort of ulcer or excavated or depressed thing, it's two C or commonly, it's gonna be some combination of those. So if it's a little bit raised off the surface and it's got a depression or an ulcer in the center, well, then it's two A plus two C or you can have it the other way round if it's mostly a depression with a bit of raised stuff around it. Two C plus two A, although it doesn't really matter about that. So long as you've got this two A plus two C uh nomenclature here, if you see something like that and you say something like that, it's almost always cancer. The Japanese classify large lesions which are two a and more than 10 millimeters essentially as laterally spreading tumors. And this is a really important classification because almost every large polyp that's bigger than, than two centimeters or especially the, the particularly large ones are gonna be some form of laterally spreading tumor. And it's really quite simply defined as anything more than 10 millimeters with a tendency to grow laterally. They're all sort of Paris two A or two A plus something, but that doesn't really matter. And they're common large polyps. And they're really important to know because there's four easy types to classify. And their importance is that they have a very variable risk of invasive cancer. So this one you can see is obviously much wider than it is higher into the lumen. It's some form of laterally spreading tumor. It's quite big, it's bumpy and all those bumps are quite uniform. So it's a LST granular homogeneous lesion, granular, meaning bumpy and homogeneous, meaning they all look the same. This similarly is an LST and it's clearly bumpy, but those bumps are all different sizes. So it's granular nodular mixed type. This is also an LST but you can see it's completely smooth. So it's not bumpy, it's LST, non granular. And this is another one that is also smooth, it's non granular. But you can see towards the right of the lesion there, there's a pseudo depression. So it's pseudo depressed type and that's it. There's either the bumpy type. So they're granular, either homogeneous or nodular mixed type or there's the smooth type. So they're non granular and they're either non granular or w which we call flat elevator, but you can just call them non granular or nongranular pseudo depressed type. You can see they've all got these Paris classifications to them. Two A or two A plus one S meaning a big nodule on it. But that just gets confusing. I would ignore that why because it's largely pointless. Look at that. LST. G homogeneous is two A LST. Non granular is also two A, they're completely different lesions. So I would ignore them and just go for the LST classification. Why? Because it's hugely informative about the risk of cancer that lesion in a whatever size it is and they can get very, very big has a less than 1% risk of invasive cancer, completely independent of the size. So there was no point going and biopsying all over the place, there was a question about risk of fibro or what, what were the risk factors for fibrosis in there? And one of the um one of one of the least uh what was the question or something about uh what was, what's not a risk factor? And LST G homogeneous lesions usually have a lovely submucosa that you can dissect with, with the ST. But if you go biopsying all over them, they definite that definitely induces fibrosis. And there's no point cos it's gonna come back most of the time unless you've seen something to biopsy as adenoma. Whereas these nodular mixed type lesions again, almost regardless of the size have about a 10 to 15% risk of invasive cancer, mostly under a nodule somewhere which is quite a substantial risk. It makes quite a big difference to what you tell the patient and what you, how you plan to resect. And that's true. If they're three or four centimeters or 10 or 12 centimeters, it seems quite consistent that rate, these non granular lesions start to get a bit dangerous when they're very small. The risk is not huge about 5% if they're less than two centimeters. But that's quite a lot for a small lesion. But when they get a bit bigger and they don't usually get huge. But when they get to four or five centimeters, it might be 20% or more. And that is very high risk. And as for these, these LST non granular pseudo depressed type, they are extremely dangerous. So whatever their size, even relatively small ones, they have a 50% or more risk of invasive cancer somewhere in there. And it's often multifocal as well. And that's why piecemeal and the MR is just an awful idea for these, they're important to recognize and that might not always be apparent on the surface. You might not see type five pit on the surface. So the morphology gives you all the information you need to know uh about managing these lesions. And so that's it really for morphology. You either have the Paris classification, which is mostly better for the smaller lesions, the common, the one centimeter or smaller things that you often see. They either protrude into the lumen and they're type one and they either look like a tree and they're type one P or they're stuck on and they're one s and one sp or they're closer to the surface and they're type two and they're either two, a, just flat, elevated or they've got some combination of depression. So they're two C or two A plus two C and only two A plus two C is pretty much a cancer. And then you've got these LSTs which again, once you get used to it, they're really quite easy to classify bumpy and either homogeneous or nodular, mixed type with ad very different risk of invasive cancer or they're smooth looking non granular and very dangerous lesions. And particularly if they're pseudo depressed, extremely dangerous lesions. And that just takes a few seconds to, to decide how high your risk is and what you're gonna tell the patient. There are a number of other really important morphological considerations and one obviously is size, which is really difficult to assess and which is why it's so poorly assessed. You get huge variation in size assessment and and it almost, it, it's really quite difficult to do properly. It's almost never correct. So what can you do? Well, you can use the biopsy forceps. Uh If they're not, if the lesion is not too huge, we usually most people use these sort of Boston uh orange ones and when they're open, they're eight millimeters. So you could use that, you can use a snare because uh that has a standard size. Remember that the snare sizes, it's transverse, it's horizontal diameter, they're often longer than they are wide. So if you have a 20 millimeter snare and it's open, you can, you can use that, but that's quite difficult for a really big lesion. And that's often where the sizing is incorrect. In fact, there was a question in that quiz that said a 45 millimeter lesion and I don't think that lesion in the picture was 45 millimeters. So, how do you do this? Well, this is just a circle, isn't it? The circumference of the bowel and a circle and this is taking up half the circumference. So whatever sort of percentage of the circumference you think is taking up, it's not super important to, to, to report what circumferences it's taking up. But if you look, that's about half the circumference for both these lesions. Well, in a circle in a, in a circle that's about PD, which is about three times the diameter. So really the colon is gonna be somewhere between sort of four and seven or eight centimeters diameter depending where you are. So the circumference is always gonna be at least about 12 to even 20 or more centimeters. So if you have these lesions in the rectum and they're taking up half the circumference, by the time these come out and you pin that out, if it's taken out en block, that's gonna be at least 10 centimeters for both those lesions, you'll often find they're reported as four or five, but they're a lot bigger and it's a simple way of looking at it and you often get it right. Other important soft signs, which if they accumulate are really quite nasty looking is look for these kind of things. Surface redness you can see in these lesions, that's just a pattern change. You're always looking for a change in pattern and you might spot cancers, you would otherwise miss or spot areas in lesions, which you should be looking at, which you otherwise would have missed with a bit of surface redness. It's, it's often quite a sinister sign, although not highly sensitive and specific. Uh it is a good sign to look for. Another thing is fold convergence. You can see here the, the mucosa sort of puckering in and that's due to a desmoplastic reaction. It can just be from scarring or some mucosal fibrosis, particularly in recurrent lesions or somebody's tackled it. Uh But if not, it can also be a bit of a sinister sign. And the other one is chicken skinning literally just looks like uh chicken uncooked chicken skin. So if you look at this here, you've got this LST non granular pseudo depressed type lesion already pretty dangerous. If you look up here, you've got fold convergence. If you look here, you've got chicken skinning. So without even looking at the surface of the thing, yet, you've got an extremely high risk of this having invasive cancer and that doesn't take long. So once you've had a look at the gross morphological features, you get a little bit more accurate and you look at the surface architecture. And that's also is another thing that can get a little bit confusing and you look at all these funny pictures and descriptions and it, it can be difficult to learn. But if you break it down into more simple terms, I think it's easy to remember and easy to recognize patterns, which is, which is what it's all about. Really, you've got these top two, which are non neoplastic and type one is just normal and it looks round and it's quite easy to spot. It's quite regular. There's just these round things, they're the openings to the glands. So they're gonna be round and regular. And the reason they look like that is that's cos of what the glands look like. Histologically, all these things look like what they do under the microscope. You've got type two, which is also non neoplastic. It's not abnormal growth as such. Uh these are hyperplastic or, or serrated lesions and they do look a little bit type like type one. But if you look closely, you'll see they're a little bit sort of spiculated, they call them stellate, but they've got these little spicules on the edges as opposed to just this round pattern. Here, you've got, these little spicules looks fairly similar. Uh and that is type two and again, histologically, that's why they look like that. Then 3 L and four doesn't really matter about, you know, have you diagnosed 3 L correctly instead of type four because they're both adenomatous and it can be difficult. And especially in this country, histology reporting is a little bit subjective. So, you know, type three and type 3 L and four are all about what's the component of villous or tubular. And so it doesn't really matter, they're all adenoma. If you see something that looks like this, it looks like regular stuff, it looks like a brain, it's three or four, you can see that it's regular type and it looks like a brain and it's probably one of the easiest to spot and it looks like that under the microscope. And then five, you do not have this regular looking stuff. Something is going wrong to some degree. You might see some pit but it's irregular or you might see nothing at all and that is dangerous and that is on its way or is invasive cancer. So you've either got these two round or looking a bit round. They're non neoplastic, these that look like a brain and they're all adenoma all this where it starts going a bit wrong and to some degree it's either on its way or it is a cancer. And then you've got the NBI I for the vascular pattern. We're often encouraged to use this nice classification. We don't like it so much it, uh but it's, it's quite simple to use. I suppose you've got type one hyperplastic, you've got type two adenoma again, the easiest to, to see really. And type three, which is also quite easy to see deep submucosal hyperplastic all very well to say, but quite, quite hard sometimes to spot because you're looking for faint pattern really. So it's fainter than the background. You can hardly see blood vessels or you've got lacey vessels causing on top. So it can get a bit confusing. But if it looks fainter than background or the same as background, probably hyperplastic. If again, you've got this network of blood vessels that around these sort of crypt openings and it looks regular like that. If it just looks like a network of vessels, then it's adenoma. And if there's a complete absence of that, then it's deep submucosal invasion. More precise is this J net classification and a little bit similar with the type one, again, type one can be a bit confusing really, I think. Uh but if it's faint or similar to background pattern or you've got lacy vessels like this causing across the top of it, then it's hyperplastic serrated. If it looks like this, a sort of regular network of vessels, it's two A which is an adenoma, the easiest to the easiest to diagnose. If it looks like this, you've got some vessels there, but they are not regular like this are, they, they are little bits here, little squiggles there, some shorter, some fatter and that is two B and that is dangerous because that could be high grade or it could be invasive cancer. I see some of you were split when it was on, there was a picture of some two B there and some of you were split about, was it ca invasive cancer? Wasn't it, was it high grade? Was it deeply invasive? Well, you were right to be split because it can actually mean any of those things. It's supposed to mean high grade dysplasia, but it can mean any of those things and you got your easy to spot T three as clearly, it's completely disrupted there. But it can be confusing. I mean, look at that, that's all type one normal at the top, lacey vessels across and faint at the bottom. But you're just looking for this faint is easy at the top there. You're just looking for these regular kind of honeycomb patterns and it is a little bit different to some of the others. Can I ask a little question here if that's ok? So you've taken us through Kudo Nice and Janet, do you mind? Just kind of like in very simple terms, explaining the difference between the three and kind of which one most people should be using? Yeah. So I think that we're encouraged to use Nice because it's simple and it's in a lot of guidelines. I think it's not particularly helpful. So nice is really similar to Janet and, and it's looking at exactly the same features Janet just gives you a bit more detail about what you're actually doing. If you look at the nice classification, it, it's very easy to spot type three and it's relatively easy to spot that. It's not an adenoma that something else is going on. But if you spot an adenoma, the important thing is, is it just an adenoma? There's no scope in here for Janet to be, or do you have a superficial cancer is something treatable by local resection or do you need surgery? And I don't think it really gives you that answer. It's good at just teaching people. Look, there's a cancer and you should diagnose that, which is important, but it's not very good. I think at discriminating anything less than that, that, that either needs surgery or local resection. So I think Janet is more useful for that, but in, in my opinion, the kudo is the mobile, it gives you the most discriminatory power and the most certainty because I think differentiating Jane T two B in these various things is very challenging. And then obviously, um the important thing is is that this is all using image enhancement. So not just white light. Yeah. So you, you've switched your NBI button on or you've switched your BL I on Fuji or your eye scan on Penta. So it's on any of the commonly used scopes, it's on all of the scopes, er, and, and you can use it and of course, the uh the Kudo pit pattern is, is using Indigo Carmine, which is widely available, easy to draw up and easy to use. So just looking at some examples, you, you, you've got this lesion here which you can see there's aspects there that are clearly adenomatous. If you have a little bit of a deep dive in there and you put some staining on it, you can see here that you've got pit, but that pit, it does not look like a brain. It is not structured, it's five eye high grade and you've got on the right there, you've turned on the NBI and you can see some squiggles of vascular pattern, but they're not regular or network at all. They're short ones, fat ones, little ones, skinny ones. So this is clearly some sort of high grade lesion. And we would say that is very likely to be superficial submucosal invasion. Uh And indeed it is and it dictates that treatment. You can diagnose it fairly confidently. You can tell the patient that and advise the appropriate treatment. Well, here you got a bit of a funny looking lesion, slightly hard to tell when on. But if you look clearly with, with some staining, you can see once again a a pattern that is, you've got definitely some sort of pit pattern there, but there's no ways that looks regular and like a brain. So it's not five N cos there's something going on there. So it must be five I, and again, you were diagnosed uh superficial invasive cancer, T one cancer and it's suitable for local resection. Here's a great example though. You, you get a, a huge lesion. This was referred as a big cecal, laterally spreading tumor. You can see there is a big laterally spreading tumor. Here in the cecum, they've looked at it, they've biopsied it, it's low grade adenoma, it's suitable for endoscopic resection. But once you take a look at it, you're looking for the pattern change and there's surface redness. I don't know if you can see it, but there it is and that is not good. That doesn't belong there in a lesion which otherwise has a less than 1% risk of cancer. So this is no longer a a low risk lesion. You're not looking at that huge sort of eight centimeter area somewhere else. All you need to do is look at this focused area. So the rest of it looks like this looks like a brain looks like a network of blood vessels. Uh and that's all adenomatous. So it's pointless biopsying any of that stuff. But if you look at this area as you go from left to right there, you can see progressively disrupted pit until you have no pit on the right there. And that's invasive cancer, deeply invasive cancer biopsies will prove the case. You don't need to wait for those. You can tell the patient they need surgery, which they did have T three cancer, which they probably should have had the first time. And you can recognize these areas quite, quite quickly and quite easily. Once you get used to looking for a pattern change and some of these important morphological characteristics and then supplement that with a bit of a closer look. Put some indigo on. If you have crystal violet, great, it is available and it's good stuff, but you don't necessarily need it. Put the indigo on, turn on the NBI button, you'll get the diagnosis. Here's another great example, completely other end of the spectrum. This is a, this is an appendix orifice lesion really challenging to resect and quite high risk endoscopic endoscopic resection of some of these. If you do it properly, this is referred up, please remove lesion around the the appendix probably probably described as as one of those other things, a mitotic lesion or something. But if you have a closer look and you put it on, I think everyone can see as soon as you put the indigo on these little red spots, they are. If you look closely a little bit spicer, a little bit rounder, it doesn't really, really matter. They are round uh blue dots and you can see the blood vessel pattern. There is very regular all of normal sort of caliber. There's no funny network to describe it as an adenoma. There's no disruption to describe it as a high grade lesion and there's nothing wrong with that pit pattern either. It's just a small round lesions. So, what would you say? Well, it's pretty much normal, isn't it? I mean, in fact, it's a sort of degree of inflammatory type, but, but it's pretty much normal. Janet one, a non neoplastic pit and he doesn't need anything at all. So, he's just discharged. So, rather than undergoing what is quite frankly a somewhat dangerous procedure, he didn't even even need to have the second colonoscopy. He doesn't need anything at all. What had happened was he'd had appendicitis about six months ago, treated conservatively uh with an appendix mass. This is just uh a bit of reaction on the inside which is all resolved and it's just regenerative kind of inflammatory tissue. It looks like a polyp at first glance. That's true. But if you just have a quick look at it, you can make the diagnosis straight away. Reassure the patient who was quite worried up to this point, he doesn't even need any treatment. So it's not just diagnosing cancers normal is an extremely important or nonneoplastic, extremely important diagnosis. So how do you make an optical di I mean, look at all the super complex, look at all these pictures, funny classifications, you can break it down and it doesn't have to be as complex as this whole thing into a series of binary decisions. Is it normal or abnormal? Is it neoplastic or nonneoplastic? Is it cancer or not? Cancer? I mean, look at the big thing. Where do you start? Well, is it normal or abnorm? It's clearly abnormal. You've got a thing that is certainly wider than it is higher. It's an LST, clearly it's bumpy, but it's not uniformly bumpy. So it's an LST granular nodular mixed type immediately. You've got a 10 to 15% risk of invasive cancer. So, it's abnormal. Is it neoplastic? Of course, you know, it's neoplastic cos it's one of these LST gene nodular mixed types. Is there surface structure? Well, yes, it is. Is it regular? It looks like a brain? So, absolutely. So it's an adenoma until you prove it. Otherwise it's got that risk of, of invasive cancer. But so far suitable for endoscopic resection. What about this one? Normal or abnormal? Clearly, it's abnormal. Is it neoplastic or non neoplastic or it's a one s lesion a little bit funny looking, clearly neoplastic. Is there a structure on the surface? Yes, there is. But is it regular? No, it's not. It doesn't look like a brain. So it's at a least high grade or possibly superficial invasion that completely changes your management. You should not remove it at the time. You should have a discussion with the patient about what they might want uh and sort it out for them depending on that. What about this one a bit more? Is it, it's definitely abnormal. What's a little bit flat and elevated, but with the depression in inside. So, two A plus A two C definitely abnormal. You already know it's gotta be cancer. Surely it's neoplastic. You have a quick look at the surface. Is there any structure? None at all? It's cancer that won't take you more than a couple of minutes and you're gonna wait for your biopsies. But you can tell the patients straight away what they've got and they'll be, and they'll be more certain about what's coming next and you can plan appropriately. There is evidence to back all this up. By the way, it's not just uh not just made up. So you put it all together basically in, in an easy way. You look at the gross morphology, you look at the surface characteristics and then you just look at technical factors. And if you remember those three things, you have everything in the report that you need and you make a diagnosis almost every time the gross morphology is the big picture, the standardized classification. Remember those other features, surface redness, full convergence, chicken skinning and, and all of that, you then go down and have a deep dive at the at the surface characteristics, at the detail, put on the indigo, quick and easy to do. Just have it drawn up. Look at the pit pattern, is it regular or not? Does it look like a brain? Has it disrupted er or is it very normal looking? And then look at the vascular pattern on the NBI by the way, it still works. The NBI after you've put on Indigo, you can do it whichever way around. I prefer doing the Indigo first. Cos I much prefer looking at pit pattern and then you look at technical factors after that really important because you can avoid the patient having another procedure so that we can or anyone else can assess it as to as to what they need. How stable is the scope, what's the access like? And what's the patient tolerance? If you have all of that, they can probably come straight to, to resection. Access is important. By the way, if you can't see the lesion properly or see all aspects of the lesion, then access has to be difficult. Uh I was asked to mention this SMS a score, you may have heard of it. Um This is supposed to help you sort of predict how difficult it is and whether you should go ahead and remove it. It's supposed to be simple and it's supposed to be user friendly. I've heard, I really don't find that's the case. If you look at it there, it's got a lot of numbers in it. I really don't know how anybody remembers this on the go. I'm not sure if you're supposed to do it afterwards and then calculate it all up and put it in. Uh I personally think it's a lot more simple because if you just look at whether it's big or there's difficult access. I think that predicts things just as well as trying to do this complicated score. So in terms of technical factors, if you have difficulty accessing it or it's bigger than about four or five centimeters, it's gonna be hard and that's good enough. And then you make a diagnosis and you make your decision once you've done that and you can do it all on the spot. Um Can I ask another little question here if that's ok? What are your kind of main bits of advice or sort of your red flags with, if, say someone that's just been signed off for colonoscopy is doing a procedure and they come across something. What are your things that you would say? Definitely don't do that, you know, rebook the patient to be done on another list. You know, what are the main things that you would say? So, II would say, don't rush anything. That's the important thing I would say that if you've just been signed off and you're happy to do a smaller polyp, then obviously fine, go ahead and do it. Although anything that you are unhappy with the size, I definitely wouldn't do it. And don't worry too much about size. If it's smaller and you still think it's difficult, it's ok if it's difficult access and you just don't think that you'll do a good job of it to leave it difficult access is I think really one of the most important determinants of successful resection and you can have a small lesion that is really hard to access and you just shouldn't do it. So I think just keep it simple. If it's big, leave it alone. If you can't get it, if you can't see it properly, then don't do it. And I think it's, it's straightforward. Clearly, something massive you're not gonna do. But if you're just worried about, look, it's a bit on the big side. There is absolutely no shame in leaving something for another day. And, you know, I would often leave something cos it's just not appropriate to do at that time. Uh You almost always regret it if you rush into something. And also, even if you think you can do it and you're slightly not happy about what you're seeing on the surface of the morphology, you think there's a risk of submucosal invasion. It's just worth careful thought about how that's going to come off and a discussion with the patient. Yeah, 100%. Absolutely. I think you should. For every, almost every polyp, all you have to do is at the beginning of the list. Draw it up in 20 ml syringes, you have it there, the nurses have it ready as soon as you see the lesion, they just shove it down the scope and you have a look at it. It, it takes you seconds. That's it. And if you have it ready and then your nursing staff are always used to that. You do that and you like it and it may catch on that. Others do it and they like it. It takes you no time and it will completely change how you look at things. It just illuminates everything for all cases, you know, polyps as well. But even if you see that things are looking a bit funny, you're not even sure what's going on, try it for, you know, the next 2030 cases just spray the cecum. I bet you'll find a whole lot of uh hyperplastic or serrated lesions. You didn't even know were there? It just illuminates everything. It's, it's great stuff. So, I mean, I'm sure you'd agree. Use it routinely. Yeah, absolutely because we often forget to clarify that we're definitely talking about. You need something to look at it. Even if that's hitting the button for NBI or B or I scan, you need something to look at it. But I would encourage you to use Indigo. A lot of people say NB is all you need. But I think once you start using it, you see just how much it illuminates and makes things easier. And remember on almost all your scopes, if you don't have magnification, almost all scopes, for example, Olymp Forss have near focus and that gives you a degree of magnification. Find the button on the scope, get used to using it all the time, really helps you look at things. So that's quite simple for the assessments, try and do it routinely for the slightly smaller polyps. The sort of Paris is quite useful, quite easy to do either protruding out, looks like a 31 P or stuck on one s or closer to the surface in some form of two A or some form of type two. All for these bigger ones, the Japanese classification getting the LST classification right, super important completely changes management and what you tell the patient and risk and all of that just by morphology alone. Um just as a as a quick one, I mean, this is what you're all getting signed off on. Uh you know, your I think this, this is I got this from what's it, the, the Dopp or whatever they call it in the in the jag thing and this is about taking off follow ups. So they're all very important. But we and here is anything about diagnosis. I mean, diagnose the lesion before you take it off, that is clearly important. Um And another quick one just, you know, get, get used to, I don't know if this is gonna actually show just move the patient look, you can hardly see there's a little thing sitting in a pool. We often get these, you know, referred to us as some sort of one s lesion. Um It's quick to turn a patient if you get used to turning the patient off and when you're assessing or when you're removing polyps, this kind of view, you can't see what's going on. There's absolutely no clarity whatsoever. You turn the patient and look at that. It just pops out at you. It's clearly a one P lesion and when you decide to take it off, it's super easy. So if you're struggling a bit to look at it, remember just to turn the patient and another quick note tattooing, please don't follow some of these guidelines that we see everywhere and often put up in units, you know, three tattoos close to the lesion. I mean, because if you're not gonna do surgery for starters that tattoo just spreads under the lesion and any manipulation of that lesion including tattooing under the lesion, destroys the submucosal plane and hugely increases risk and it spreads hugely when, when we put in tattoo and tell all your gastroenterology colleagues as well because they don't have to do the surgery, go some distance from the lesion. We know surgically what do you care if it's, you know, 5, 10 centimeters away from the lesion? And certainly if you're going for endoscopic resection, either diagnose it as going for endoscopic resection, don't bother tattooing it or if you're not sure tattoo miles away. I just use this as an example. This is one I tattooed you can see on the image on the left that is 0.5 mils of tattoo. There's hardly anything I've done it on the anti Mesenteric side and that's what it looks like at laparoscopy. It's quite easy to see and it's right there. It's not spread all over the place and destroying your planes. So use it cleverly make sure you're on the anti mesenteric side. Put a tiny bit in, you don't need to overdo it and tell your colleagues not to overdo it either. So, you know, summary optical diagnosis helps you perform a meaningful assessment and diagnosis of colorectal lesions. That's it. It really does help and I would get into it. Put the stains on, press the button. Look, it's really, really enjoyable to diagnose things correctly. It helps the patients and it's a beautiful world out there. I mean, look at these images, this is patients like it as well. You show them these images and you'll use less sedation, they enjoy their colonoscopy a lot more. So I hope that's been helpful and I hope it helps you enjoy your colonoscopy and diagnosis a bit more and make some meaningful decisions. Great. Thank you very much, Andrew. Really? This is an excellent overview of optical diagnosis. I think what we'll do is there are a few questions on the chat which I think will answer as we go along. But what I'm keen to do before close at nine, Katie with your permission is to run that quiz again and just go through the answers and then we can also answer some of the questions on the chat at the same time. So let me just share my presentation again. Please bear with me. So, um let's, I'm hoping you can see that, Katie. So let's go to question one. We'll do this fairly quickly now because you know what you're doing, what is the appropriate Paris classification for these lesions for those three lesions? 12 and three ABC or D have a quick look at that and let's see what the polling is. You put the pole up, please, Katie. And how are we doing on that? Yeah, we've got a few responses. Please do have a go guys and test your knowledge after that excellent lecture. Yeah, we'll stop it there. So this time around, we have got 11% have said a, nobody said B 55% said C and 30% said D so OK. So, I mean, that's, that's certainly the majority here have said C which is the right answer. You got one P as Andrew had shown with a stalk and then two A and then you've got two C plus two A lesion which is a depressed area. And of course, um uh what, what he had shown was that this was a classification. And just to remind everybody that what he was looking at in that lecture, the protruded type one P for one, you've got the flat lesion, which is obviously the two, which is the two A lesion. And then you've got a two C plus two, a lesion as a depression three. So good question. Two pit pattern guys, you got both Indica Carine staining and crystal violet staining for those four polyps, the surface characteristics on Kudo pit pattern. Um Let's see if you can answer this ABC or D, let's put the poles up Katie and give people some time. OK. How are we doing? So we've got 35% have said a 42 have said B 27 have said C and no one has said D so very similar to last time around actually. OK. Um And actually, to be honest with you, I think the ones the majority have said um A or B which is, which is good and that's very encouraging because actually A and B have, have got the same sort of similar overall diagnosis, either being adenoma or non neoplastic or early cancer or high grade or an adenoma. So actually, I think that's very encouraging. So I put them together nonneoplastic adenoma. The majority of people have got that right? Which is excellent. OK. So the third question, remember you saw this lesion in the right colon? So what would you do with that? Let's have a look at that ABC or D, what do you think guys, if you put the pollies up? OK. So we'll close it there. So we've got 8% said hyperplastic, 8% said cancer, 30% said adenoma and 53% said SSL OK. Um good. I think, you know, the majority of people have essentially said that this is a benign lesion that needs polypectomy, which is either C or D. So that's encouraging in terms of you having to look at this sometimes it is difficult to know that distinction just on spectral imaging and on this is on actually on the fuji scope. So encouraging that you've looked at this is the benign lesion that needs polypectomy. So that's good. It's good improvement. I think that's an excellent example of why indigo is great, isn't it? Because as I said, Janet one can be confusing, you know, you've got faint pattern or it looks like the background or it's lacy vessels causing if you chuck indigo on that, it's going to be obvious straight away. No, exactly. The other thing I was going to ask about this one is obviously the question part of the clue is the location of the lesion. So what would you say to people listening about hyperplastic polyps in the right colon? Yeah, I think, you know, we've got to be cautious, haven't we? Because of this right colonic lesions that are that I've got this sort of appearance there. You got to think about whether this is actually se ulcerated lesion, ah which has got evidence of dysplasia or not. So they need to be assessed carefully. You wouldn't really think about leaving these ones in the right colon in situ if they're in the rectum and they're small then that's appropriate to leave them in situ. But if it's in the right colon, do think about c ulcerated lesions rather than just them being simple. Hyperplastic polyps. Yeah, I agree. Entirely. Remove everything in the right colon as far as I'm concerned in the right colon. Hyperplastic is just on a spectrum to serrate it and remove it. Yeah. No, absolutely. OK. So, question four. What do we think here? What did you think was the Paris classification? We either? And what would you do? I think there was a fairly good response last time. Um Have we changed people's minds here? 83% of people said b last time, what have we got this time, Katie, let's put the polls up. Yeah. So this time around we've got 89% of people have said B and then just a few people have said C and D. OK. OK. Good. So that's, that's absolutely right. This is obviously LS TG mix nodular type. Uh Andrew was saying you get the size wrong. Think about the circumference using half of the, it's actually occupying nearly half of that circumference. So the likelihood is it is probably twice the size of what was stated and referred as there. Um OK. And of course, you know, there are a King's algorithm which I'm not going to go through about what we do. But Andrew's gone through that very carefully about proper diagnosis and then making a decision regarding treatment for ESD. So answer question five guys, what's the Janet vascular pattern here of this lesion that I think I'm just going to skip through this because actually this was Janet type two B, what we were looking for most of you actually had said in the previous one that it was B and C, which is good because it's Janet type two A which is in the periphery that you can see. And then it's type two B centrally, which is the irregular vascular pattern. So I think all of you had said B and C last time you can now just have that clarity and detail. This is the most advanced TB. And of course, hopefully, as we know, now there's a pseudo depressed component, there isn't there, which is really important. So again, morphology is key here. When you look at the surface, you know, you've got a problem. No, absolutely. And this is where we would always advise you to use uh you know, chromoendoscopy to assess that in detail and look at the pit pattern, cos it will give you a bit more of an indication of what the diagnosis is and how we would manage this patient either endoscopically or, or surgically. OK. So that's the Janet classification that Andrew was talking about earlier. I'm not going to go through that. So finally, um two more questions guys, what do we think here? Question six. Did we think this was um uh as this polyp or an adenoma or superficial T one cancer uh or needing endoscopic resection or do we think this is deep, deep, some because of invasive cancer, needing surgery A or B, we'll give you a few minutes just to answer that. OK. So let's get the pole up. Yeah. Are you more in favor of a or more in favor of B Katie over to you? So we have got 63% this time said A. OK. So more people gone for a this time rather than B uh and just to go through that, this is um it's 20 millimeters. Janet type two B for the vascular pattern there, which is five I, what we would call five I low grade pit pattern. And this patient went on to have ESD and endoscopic treatment and this was a adenoma with high grade dysplasia. So you are right to say that this patient needs to go on to have endoscopic resection well done. And then finally question seven, which of the following factors is least recognized as contributing to scarring or fibrosis. Is those five options? A to e let's also let's uh get the pole up to see it was a varied answers last time. So most people this time around have said LS TG homogenous type was the least likely excellent. I think they were listening tentatively to, to you, Andrew, which is uh which is very encouraging. So thank you very much so, really encouraging actually, that there's been huge improvement in the quiz to the answers that we would have expected you to get. So I think I'm really very pleased that you've joined in with that. Over to you, Katie. There are a couple of questions. Do you mind if we just answer one or two quickly? So we've got one that says when you do an ASD, do you take all of the submucosa? So, is it OK for T one? Cancers? I wonder if uh Well, Amin's gonna answer. I mean, whilst you're answering, that should I quickly bring up? We, we had some cases to discuss which we weren't. But as he's talking, um as we are usually of one mind, I'm sure I know what he's going to say. And then I can show you some pictures to demonstrate. I think what's really important is to ensure that we are in the deep submucosa, taking the trunks of the vessels close to the muscle layer. At the end of the procedure, we should just be seeing white muscle that's clear rather than any submucosal plane or hazy vessels that are there. So it's really important to examine the scar and you should have white clear muscle. Um And that means you've taken all of the submucosa because if you've got patients with early cancer and you don't take all of the vessel and the base of the vessel, the trunk of the vessel, then you may miss some vascular invasion in that particular area. And what we often do histologically, we stain for muscle to ensure that we can actually see some of that stain in the deep sub mucosa is showing up there, what you're saying. Yeah, absolutely showing up. That's perfect. And you can see exactly what you were saying about the vessel. There, there is a bit where we've, we've treated a massive feeding vessel right off, off the muscle and you can see the full submucosa has to have been taken there in every case. And this is a good demonstration here of exactly what I mean saying, why it's important. There's a small part here, only 15 millimeters. But if you take a close look, five eye pit, we diagnose SUFI T one cancer. Why can't you just er, well, you can, and you might get it out. But if you did even a small lesion, you can see the muscle layer there. You've taken the full submucosa and this is at one with one millimeter clearance. You may not get that clearance with the er and then you're stuck with. What do you tell the patients? So, yeah, absolutely. You get the full sub mucosa and even more than that in the rectum. What can you do? What do you think we were going to talk about plane of resection? But what do you think? I mean, we get under it and we see that we can take that in the normal plane just off the muscle. But what about this one? And we see, and we see that on the left. Well, then we would often go intermuscular here and you can just take a small section of isolated intermuscular dissection. And as amine said, stain for that muscle, there's at two cancer and you can be quite clear where it is and that you've got muscle and there's no recurrence here uh on surveillance because you've got that. And if it's even deeply invasive, you can decide to go full thickness and close it up. Or if you're in the sigmoid like this, you can just go through in the submucosal plane. So you don't cause any defects. You can see very clearly at ESD exactly where you are and take what's necessary that leads on to one of the next questions that's about whether or not they can report SM two SM three. For example, I absolutely. And here's an example of why you can and why we prefer it, for example, to, to ts you've gone under the lesion, you know, there's cancer there patients comorbid doesn't want surgery. You get into the intermuscular plane, you can see these intramuscular fibers very clear. You know, you've got circular longitudinal, you can see that second layer very clearly here. And even once you're in that it's all nice and clean and then you hit this area, it doesn't look so clean, you're not quite sure is that desmoplastic or is that going a little bit deeper? In which case, you can then just decide to take that area as full thickness. So you don't have a huge defect, you've just done it very accurately. And then you can absolutely stain the muscle again. T two clear. And then one final question was about, um, do you always use dye for Kudo? I think that comes into the technicalities of how it was described originally. Yeah. No, absolutely. I think when Professor Kudo and please do come to King's live guys because Professor Kudo will be there and it's probably the last time they will be traveling to the UK before he retires. Um So you can listen to him and chat to him over dinner. Um But yes, always he he described it using indigo carmine and crystal violet. Crystal violet is very is important for looking at five pit pattern. Um because actually for the enthusiasts, we differentiate not only between five I and five N, but we also subdivide five I into a bit more detail of low grade and high grade. So crystal violet is important just to get that detail. Um But yes, Indigo Carmine can be used for looking at type one to type four. So yeah, you must use chromoendoscopy for Kudo. That's what I was originally described, which everybody can learn quite easily if you just do it a few times and keep doing it. Yeah. Well, I think we've run over a little bit over time, so I think we'll wrap things up there. Um, I've just put the, um, QR code on for King's Live again. Um, as I said, it is a really great event and I would definitely encourage people to go to that. Um, there's lots of lots to learn there. Um, and then just a final reminder that next week is the last in our Fundamental series. And we've got um Bjorn Rebeck and speaking, he's a um gastroenterologist up in Leeds. Um And I'm sure that um the these guys will attest that he's, he's a very good speaker as well. Um So I think that would be a really great session and that's all about how do we actually manage these polyps when we find them? So, um I'd like to say a huge thank you to Mr Mr Emmanuel. I really appreciate your time this evening. I think it's been a brilliant talk and I've learned lots. So, thank you very much. Thank you for having us. Thank you for having us, Katie. Have a good evening guys. And if you please do email Katie and the Dukes Club to get your free um to get your code to attend King's Live for free. So, um do that and we'll send you the code. Brilliant. Thank you. Ok, great. Thank you.