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Great. So we should be live now. So good evening. Um Everybody that's joined us this evening for the third part in our Dukes Club Fundamentals of Colonoscopy webinar series. Um So I'm Katie, I'm the Endoscopy Rep for, for the Dukes Club. And we're really lucky this evening to be joined by another amazing speaker. So we've got Doctor Bjorn Rem back in with us this evening, who's a consultant, gastroenterologist up in Leeds and he is a national expert in the management of complex polyps and is very well known for being um incredible at er um and he's also been part of many guidelines written by the European Society of Gastrointestinal Endoscopist. So we've got a real expert with us tonight to talk us through all things polypectomy. So without further ado, I'll pass you over to doctor RBA um similar to last week and the week before we're happy to take questions as we go along. So if you have any, please do post them in the chat and we'll ask them. So over to you, Doctor Renck. Thank you. Thanks a lot, Katie. So uh thanks for, for joining me then and listen to my presentation. Katie builds me up as if I have some sort of, you know, the, the, the final arbiter of E Mr and Polypectomy and stuff. But I'm, I'm, I, the first admit that and polypectomy is not an easy thing. There's so many variables that go into that. I think the outcome is unpredictable. And what I'm gonna talk to you about tonight is, is my way of doing it, you know. But that it, it's like cooking. It doesn't mean that it's the only way to do it, you know. So you might have your own ways of, of, of doing stuff, developing your own things that you're, you're comfortable with. But, you know, uh it's not prescriptive. Um, Kate has reminded me that you've already been through two presentations about lesion recognition and stuff. So, II might actually ask you a few questions about what you think I'm showing on the slides, you know, to see if you, if you learned anything from it anyway. Endoscopy is not a AAA simple thing. The, the kind of the four things that I go through when I, when I think about polypectomy is, is these the four A, is it appropriate? Can I anticipate trouble here, please? Oh, sorry. Do I need to do it again? Ok. Bear with me. So, can you see that guys? Great. Uh Oh, here we go. So the four A again, is it appropriate? Can I anticipate trouble? How should I approach it? And when should I abort and, uh, and send it to you guys? He's off the friendly surgery to sort this out, um, appropriateness. Uh, and this is the reason II really dislike being called into another room to, to help out with a polypectomy because you don't know any of this stuff. Of course, when you called in is, is it, has the patient been consented? Does he know that there's a late bleeding risk of one in one in 30? Has he been told that there is up to one in 100 risk of a perforation? You know, our clips are great nowadays, it's probably far unlikely that we, that we're gonna need to turn to the surgeons to do Hartmans or something like that, you know, but, but you know, it, it should be mentioned to the patient is, is the lesion cancer that I can probably tell in the room and, and put brakes on a biopsy. So we'll see what that shows before we attack it. Um Is the patient uncomfortable to me? That's a showstopper if the patient is uncomfortable, I'd like to know that before I embark on my, on my polypectomy because then, then, you know, by the time I kind of mid the Mr or whatever, I'm kind of commit to that, I don't want to stop. So if the patient is a slightly bit uncomfortable, I will stop before I attack. Um Well, you guys should ask yourself, I'm not the right person for this SMS A score. The SMS A score is, you know, the um you know, it, it, it's, it's one way to kind of quantifying estimating the difficult level of removing that polyp. And if you don't think that you could remove this level four polyp, which is kind of a flat polyp in the right hemicolon with difficult access, maybe with a gamma loop in the transfer or something, they gonna say pass the back, let someone else sweat over it. Don't, don't do, don't take it on yourself. Is it the right patient? And I think this slide is a, is a good example. Um So, so this is a um what, well, what part of classification do you think that is or, or in plain language? Er the options are sessile, er later spreading tumor granular type or later spread in tumor, non granular type. I guess those are the three that you might think about. Um So I should mention this was a 97 year old patient. Uh that got this thing seen on CT C. Oh, it's not fit for a colonoscopy. Bloody. Hell, not only as having a colonoscopy, he's, he's potentially having a big er as well, you know, he's gone, gone a long way since he was seen in clinic age 97 walk, barely, barely walking into the assessment room. So I would call this sessile, you know, er because it's kind of dome shaped on a, on a flat kind of fall that is arising from II will I eyeball this kind of thing? And see there is nothing, there's nothing indurated. There is no areas where the crypt patterns kind of gone missing that I can't, can't see in the crypt everything. Well, it looks a bit knobbly but that to me tells me that it's probably ok, it's probably of the latter spreading to a granular type, you know where it's like, like cobblestones to put together. So, to me this is a reassuring polyp and, and II bailed, I bought two biopsies, either biopsies against all. Lord says. Yeah, we're very worried about this high grade dysplasia. Then, er, I would have to think again, very hard, but as it is 97 I'll be hard, pushed to attack anything at that age, I think. Um, now anticipate trouble. And the, the first, the first thing that I've got the greatest respect for is patient with a history of ati a or stroke because you stopped the blood thinners or, or, or their, do whatever they're on and they got a very high risk of stroking out. We've had patients in leeds, had a stroke, been taken out to their, to their car in their wheelchairs. We've had patients having a stroke the next day and then of course, you, you think carefully, blood the hell did I need to stop the blood thinners? Did I really need to stop it? For a week after this, I mean, bleeding, I can deal with late bleed, you know, on the whole, on the whole, it's not the same level of disaster as, as a stroke is. So I got the greater respect for stroke and II think is it with you rewriting the guidelines now and, and basically move towards leaving people on the anticoagulants, er, whilst the polyp has been removed because we've got some excellent clips there. And you know, this is a good example, kind of a subpedunculated. I would call this. It's got a gyrate pattern. So it's probably tubulovillous adenoma. I I might be alone on this, but I would be happy removing this thing in someone who is on a, on a blood thinner or maybe I stopped the blood thinner that day because I can put, you know, normally I put five clips on hell if they're on blood thinners, I put, I put 15 on whatever number. So it's like it could be like a picker fence. I can't put any more on that thing is not gonna bleed. So I think the guidelines need to move a little bit. So now I'm I'm II got a higher threshold for stopping the anticoagulants and I got a very, a very low threshold for restarting it the same day when the clips are in place. I'm happy, I'm telling the patient, you know, that of course, you might have a late bleed after this, but we can deal with that. Don't worry about it. George or Mr Smith. Mr Smith, we can deal with that, but I can't deal with a stroke and you don't want another stroke. Do you, do you remember what happened last year? You know, the, the, the, the, the, um, the power in your arm came back? But you don't want, you don't want to have that again. Do you? They see that, they see the point because they've been that close to having been paralyzed and they don't want to run the risk again. So, yeah, I think that's the way the, er, the wind is, is moving anyway. Anticipate trouble, better access in retroversion. Any polyp in the left hemi colon is usually better accessed in, in, in the retroversion, you see the, the picture here, the top left one, the shaft of the scope kind of pushes past the polyp so it faces towards you. When you put a twist on the scope, you can, then it's kind of presented to you by the, by the shaft of the scope shoving it forward. So most things in the left Emmi colon are virtually all actually. Yeah. No, all, yeah, all, all of the polyps in the left colon are removed with a, with a gastroscope in retroversion. And, er, if I can retrovert in the, the, some of the horrible stigmas we get in leeds, you know, you can, you can't retrovert, it's too tight. But I still use a gastroscope. Um, turn the patient so the blood drains away if there is bleeding and sooner or later will be bleeding. Let's face it. That's, that's perhaps not a, not a, not a, a bad idea. Uh, hold on. Can you still see me? So you have frozen? Your picture's frozen but we can hear you. Uh, that's all, isn't it? I wonder what that's all about. Uh, uh, try to turn your camera on and off. It's integral to the uh uh uh let's, let's go to settings. How about now? Yeah. Odd. Maybe just stop your video for a second and start the video again. Uh Screen sharing. OK. OK. Let's, let's try that. Mm Yeah. Weird. It could just, it could be my Yeah, we can still hear you and see the presentation. OK? Yeah, let me um maybe I should switch off my uh my bit defender in the background in case there's something to do with that. B isn't it? Mm. Yeah. No, it doesn't appear to be that either. Odd. Uh Yeah, maybe he died. We can still hear you. Ok. So should we press on? Uh Yeah, and we'll see if it comes back. Um Anyway, uh So how, how will you deal with bleeding? Well, tell the nurse how you're planning to deal with bleeding. That's uh you know, and there are different options. If you've got a pedunculated polyp, you want to recast the peduncle. If it, if it bleeds, er, if you got, um, uh, if you haven't got ap ankle, it's a flat polyp. You know, you can use a hot pipes or forceps, you can use one of these very expensive coa grasps you can use the tip of the snap, which I tend not to, to be honest, I don't, I don't like using the tip of the SN because it, um, if the patient sneezes when the tip of the sn is like, you could potentially go straight through the colon, which I would like to do and put clips on, on the whole, I put the clips on. Last, I like to get the, er, hemo er, hemostasis, er, initially with the hot pipes and forceps and then once it's dry, er, I then put a clip on. The other thing I do if there's been bleeding is um, er, I wash out all the blood to kind of clean the area because I always tell the patients afterwards, look, er, come back, if there is blood and clots in the toilet because then you, then this, this, this polypectomy side is bleeding, you need to come back in hospital for a check up. But if there's a bit of blood on the toilet paper, don't worry about that. But of course, if there's lots of clots and stuff in the, in the around the polypectomy site, the patient will finish, procedure will go out, have a trump in the polyp and then come ring back in again and he's, he's bleeding already. There's loads of loads of clots saying, what are you going to do about it? Oh, Christ. So always, always clean the area up. So it looks kind of presentable. So the, the patient will be back in again. It would be a debacle, the whole thing. Uh, possible approaches, er, of course, this is the repertoire of how you can remove things, er, cold ner hot ner E Mr ESD er or, or, or the latest guy on the block which is under water. Er E Mr um Now I hope you can see this, this video here. So can you see that Rolling Katie? Yeah. Yeah, great. So that this is me injecting a polyp in the ascending colon and um and I got a new, a new fledgling endoscopy fellow next to me. So he, I then give the snare to him on the left hand side and I asked him to try to remove and he, he really cocks it up. So after a few minutes I take over and II place a snap over the polyp and that will be the right hand. So now I'm on the right, my endoscopy fellow, my beginner endoscopy fellow is on the left hand side and it's just to illustrate that, you know, we can talk about these things, but actually in the end, it's a bit like cycling, you just have to get on the bike and, and learn how to do it and, you know, so, so you need practice basically before you, before you're good at it and, and just, just accept that, you know, um, it's the, the, it is what it is. Er, did you see that he gave up after three minutes? I can't do it. Ok. Fine. I'll take over, er, but he soon learned, you know, he's, he's still hacking away here. Yeah. No, can't do it. And at this point I've got the sta around it and I'm just lobbing it off there. Er, gyrate kind of crypt patterns is a tubulous adenoma. Of course, I'm also about how to, maybe you're going to come on to it later but how do you master the tip control to make it look slick, you know, any tips, practice, practice Katie. There is. No. Yeah, it's like how the hell do I strike the ball, the ball? How do I use my driver in golf? You asked how to practice? You know, there's no other, there's another word for it. Um, yeah. And, but it, it comes pretty quickly so you'll soon get good at it. Uh, so cold snaring. Er, so here's a, here's a kind of cold snar, a lesion in the, in the right hand margin there. What do you think that is guys, um, what kind of lesion do you think that is if anyone wants to put their diagnosis in the chart? Histology? What's the histology and what we, yeah, what's the histology? What, what is this? Basically? It looks like an SSL to me. Er, yes, you're absolutely right. It's an SSL, of course, ERD lesion. Er, finally we used to ignore them for years and years but now we, we remove them because they can very, occasionally, er, er, be malignant, of course. Uh, so cold snaring, um, our co lesions up to 1012 millimeters on the whole. I use the, personally I use the med works a cold now called the Cross Cross Zero because it's a metal sheet and it doesn't kind of concer, it doesn't compress as you use it and it's got a very thin wire. So it's excellent. It's the best thing for cold snaring really while a lot of the others got too much tissue in the snare, you will concertina, the snare sheet and you can't and, and it doesn't cut through. Um, I always put, by the way, I always put clips on the patients on the blood thinner. You know, it said that look cold is very low risk of, of late bleeding. And of course, it is not, I don't think because we're not using heat but because we're using it for very thin lesions like this, this sa cell here in the, in the corona, it doesn't have any big vessels going into it. It can always rely on, on diffusion through the mucosa to, to kind of nourish it. Uh So it's II think that the low risk of leg bleeding is to do with the growth morphology rather than the actual way of removing it. So, queerer something Katie asked me, should I, should we cold snare this thing or should we e mr it? And so this thing, er, it is from a couple of week ago. Er, I choose because it's bigger than 12 millimeters. II choose to, er, er, it, because it's quicker. So here I inject in inside it, put a snare around it. Bang, done. So that's way quicker than, than doing a, a piecemeal a, um, a cold. The only thing if you do this, there's one thing I should mention and that is you've got a lot of tissue and that's now tell the nurse put the diathermy on, on as pure C as you can because there's no vessels to worry about. So put, I'll put her on effect level one, the, the herb diathermy that we use and I'll tell the nurse close as fast as you can. You don't need to worry about, about, um, er, scenario this slowly to kind of coagulate and then sss, there are no vessels and you don't want to overcook it. I have had cases like this where there's been late cirrhosal burns, Post Polypectomy syndrome, which, which you don't want. Of course, because I was, I was cutting too slowly. So you want to cut really, really fast and you, you spoke about it at the start. I, about how it, yeah, there's no right way or wrong way to remove polyps. Yeah. This you're showing here is probably 1520 millimeter SSL. Yeah. What's your thoughts about cold? Staring that in multiple pieces? Yeah. Yeah. There's nothing wrong with it. You can do it. It takes, it takes longer and I'm an impatient kind of guy so I want to be kind of quick about it And the other. Yeah. Yeah. So that's my only, you know, but it'll be just as effective removing it, um, by, by a piecemeal. Absolutely. That's something quite specific to SSL S though. If it was a flat adenoma is definitely the way to go, would you say? Yeah, because there is always the possibility that, that adenoma has got some high grade dysplasia and stuff and then it would be nice to have that single, single piece removed, I think. Yeah. Absolutely. Um, so hot snare then of course I do for pedunculated polyps. And here's an example of pedunculated polyp question to you guys. Where would you put the snare, er, A at location A B or C? What, what do you think people wanna post anything in the chart? Where is the right place? There are, there are a few right things so to speak. Uh, most people are saying B yeah, you're right. Of course, it's B er A, you don't get, you don't get the, er, bit of polyp stove to come out for the histopathology to tell you. Yeah, you got complete resection. If you put it at sea, you haven't got a stone to grab, hold on if it bleeds. So B is the right place to, to, to do it. Another thing that is sometimes mentioned is should I do, should I do a bit of coagulation for, I mean, a thin, thin stalk like this? There's no need to, but for a thick stalk, you might think should I do coagulation first and then finish with a cut. Uh But remember that the vessels are in the center of the stalk. So if anything, you should do the opposite, you should do cut first in the periphery of the store, but there are no vessels and then finish with coagulation. Um And nobody does that. I don't think instead what in leeds II tell II, don't close the snare myself because more often than not, I got one hand, you know, left hand on the wheel and the right hand is on the, on the by the by, you know, holding on to the the shaft of the, of the snare. Er II tell the nurse look, squeeze, squeeze quite hard to start with and often if it's a new nose haven't worked with before I grab hold of their arm and I squeeze their arm. I say squeeze that hard. Er and when you see it start cutting through, when you see it kind of goes zip, zip. So it's beginning to cut away, then don't close the snare anymore because the tension in the wire will do the, will do the, the last bit for us at the right speed. Er, instead if you don't tell the nurse that you often get the, the exact opposite, they start off very, very slowly, kind of cautiously and when, then nothing happens and they go bloody hell nothing's happening and they, and they really squeeze hard at the end, which is, of course, the abs absolutely the opposite of what they should be doing. Um So, so that's, that's how I, how I deal with it. There are another few pointers about pedunculated polyp, take the tension of the stalk. If you can, if I particularly the sigmoid, you grab a hold of it and then the patients sneeze at a bit and before you know it, that stalk is stretched like a rubber. If you now cut the, the little pesca thing will disappear around the corner and if it then bleeds you, you, you inches away from it and it might be a little bit difficult to navigate back. So make sure you haven't got the stroke and the tension because it will ping back and disappear and you lose kind of control of where you are. Uh And, and you know, in the tight sigmoid, it doesn't take much blood to fill that up. And before you know it, you don't, you don't know, where was the stroke on the right side, on the left side, up or down? Hell, there's blood all over the place and the, the whole thing gets a bit fraught. So take the tension off the stoke before you cut through it, pre injecting the peed uncle. I usually do that, you know. Uh, not because II think it, it makes much difference to the, er, to the, you know, the immediate bleeding rate. But if you see in my next picture here, I think it kind of highlights where the stalk is and whether polyp starts, it can sometimes be a bit tricky. So it's easier for them for me to then to put the snare around and say, yeah, II think I got that polyp. I think it's all in the stalk because it's blue on one side, it's kind of red on the other. I can cut through here. I'm probably in the right kind of place. So that's why I often preinject the period uncle um Olympus Endo loop. I think they call it the ligating device. Now, I don't know if you, if you've heard of that or, or used it Katy in, in Portsmouth. It's infernal piece of kit made by Olympus that um basically it is a detachable loop you put over the, over the store, you can then kind of detach it and then um take the introducer out, go in with your snare. But what we in the habit is that you then place a snare around the stalk and you've got the blood in the loop in that. So you now can't cut through because you've got plastic in the, in, in, inside your snare and, and quite often it's more, it's causing more trouble than it's, than it's worth. But, um, it's worth practicing on easy polyps. So, if you have, if you got a big scary polyp, if you got the endoloop in place and never had a late bleed from it, you know, if you can get it on right. You know, quite often, it's easier to love the, the, the, the cut, cut off the polyp and then place the end loop over the stump, so to speak. Provided you left the str to, to, to um attach it to um pre clipping. The pe uncle is something I don't do because for the very simple reason is that it, it kind of works as a, as a lighting conductor. And when you put the, the snare around it, you can actually then get short short circuiting of the um the electricity goes through the tip of the, of the clip now resting against the mucosa somewhere and you kind of lose control of where the power is going. So I don't, I don't ever pre cip the repeated uncle. I mean, some people might find it working, but to be honest, I never heard of anyone singing its praises. So I think it's probably not worth doing, to be honest. Er, E Mr then. Well, Ie Mr, what the definition of E MRI guess is when you inject underneath something and then put a single, single sn around it, er, and, er, and lob it off and, and I do that for anything which I think looks a little bit on the odd side. So this polyp here, er, is the rarest of colonic polyps is really, I don't know if you've seen this in the previous, er, presentation guys. Does anyone recognize this? What that is? Looks like an ssl of dysplasia? It does it in a sense. It is, but it isn't because it hasn't got, it kind of got a weird kind of spaghetti surface. It's actually a, um, a traditional, a TSA, a traditional serrated adenoma, er, which is, there's only, I think about 1% of polyps are, are this kind of thing and, er, they're rare but they're probably maybe a little bit more likely to harbor cancer than the average polyps but difficult to tell because there's so few of them. So anything which looks a bit weird I remove by E Mr, to be honest, uh, be careful how much you inject someone, um, in the, in the kind of discussion earlier thought I injected a lot for that. E Mr, you might be right. I inject less now than I used to do, uh, maybe 30 years ago. And in this injection picture down at the bottom here, I think I over injected because now, so II lift, not just the lesion but the kind of the, the, the normal mucosa around the lesion. And all of a sudden it's actually more difficult to grab hold of this than it would have been if I stopped five minutes ago. So you can over inject things, try stop injecting when you lifted the polyp. But before the kind of the shoulders are beginning to lift of the normal nearby mucosa, so you, you can over inject uh and here we go. So which snare should you use? Well, it depends what kind of lift you have. If you've got good lift, you use a um a a um any, any joing snare really I tend to use for a chunky polyp like this that you want to have a fair bit of coagulation underneath it. I would use an Olympus braided snare. Say the snare must a snap for something on the right hand side that this is a Yeah, what is that? I should have asked you that, shouldn't I that what what polyp that is that, that uh well, before I lifted it, it was a later spreading to non granular type. Now with a, with a lift, they're always relentless and terrible at lifting. It almost looked like it's a ladder spreading, tumor depressed type because it kind of concave in the middle. But I think that's an artifact of, of the fact that it's these, these bloody things never lift. Well, ever, ever. And, and when you've got a poor lift like this, you need a really, really stiff snare and the stiffest snare on the market is the, the fuji film slash med works. Um, er, flat band snare or I think they call them flat ribbon. Now. It's a more, it's a, it's a single kind of square piece of steel and you, it comes in three sizes 30 millimeters, 22 millimeters and 10 millimeters. And that's my go to snare for, for d poorly lifting polyps. So I would use the 30 millimeter snare and you push that down and, and the squidge a bit in the middle where you just kind of protrude up like stepping on a piece of mud and it squeezes up between your toes kind of thing and, and then you can grab hold of it. Word of warning though, because that, you know, you can have muscle propria, you can have anything underneath that underneath inside the snap by the time you close it. So you have to be prepared. It's a nuclear weapon. You have to be prepared for, for problems afterwards. Ie perforations and be very careful with it. Um I, I don't know if any of you guys go to the British Society Gas Controlling meeting the B SG. There was a, there was a famous case when my, my colleague and friend um er Brian Saunders did a polyp rectal polypectomy with a flat pans and, and promptly perforated the, the, the, the, the, the rectum. And I think that was a terrible, terrible setback for med work because I don't think anyone used their, their flat bands there for years afterwards. And in fact, the, when I, when they got the 30 millimeters snare out, flat band snare out and I started using it, they said, you know, Dr Ram, and we're very grateful because you're the only guy in the whole of the United Kingdom that uses this 30 millimeters there. I wish you could tell people that it's a good piece of kit. It is a good piece of kit but it comes with, it comes with, with great power comes great responsibility. So you've got a question here from one of the um audience there. Yeah. Far away. Would you stop and take a biopsy if it's not lifting? So if someone were to have this polyp in front of them that it doesn't look too big if it doesn't lift. Well, what would you advise? No, if it doesn't lift, I would have uh you know, if, if it, if LST NG, if that doesn't lift and is really not lifting at all, not budging an inch, I would then put a tattoo down and say, look guys, I can't remove this. This is for you. This is for you surgeons to remove. I can't remove it. If I think it's because it's been, it's been sampled to death before or it's in a segment of colitis. That's another thing that gives you poor lifting. Even though it's a benign lesion, then, you know, you can hack it out with. If I, if I put my, if I use the 10 millimeter flat band snare, I can, I can scrape off more or less anything and any little bit that didn't come out I could. A PC is more of a question. Is it appropriate to do that? And of course, the obvious reason why something is listening is that it is in fact malignant. And then if you then hack that out piece meal and the whole thing is a bit shambolic. Someone will, will, could ask you the question. Well, bloody hell, you got this, this cancer out in multiple pieces. But shouldn't this have gone to the, you know, colorectal MDT beforehand? Shouldn't he have a staging, um, CTS beforehand? We're a bit of a mess now, aren't we? So, um, appropriateness you have to use your, your, your judgment here. I think if it is the right thing to do. And I think as well bearing in mind that for most endoscopist, if you're not an expert in EMR or ESD, then if you think it's beyond your capabilities, rebooking it for someone who might be capable of doing it. Is that yes. Yeah, absolutely. Yeah. You know, there is, it's the first rule of medicine in that book, isn't it? Um, if, if possible pass the buck, you can't beat it, you know. Absolutely. Um, so, II, you know, sadly the buck stops with me. But, um, yeah, and, and I, on the whole, I, I use, I use the, the, the, the non lifting sign as a, as a way to kind of prove to myself and everyone that my endoscopic impression that this is cancer is correct and is to get out of jail car. Because the, the problem with the biopsies, you see guys is that the histopathologist, they need submucosa to make a diagnosis of cancer. Uh If they have got submucosa, the only thing they can say is that this is high grade dysplasia. And of course, what then happens is that well, Doctor Ram and is on high grade dysplasia, you should go back and have a go at it and, and that has happened in the past um, eye ball polyps. I don't want, I don't like the look of this. Let's take some biopsies. Oh, no, it's benign, come back and do it and then you might end up in the uncomfortable situation of hacking out a really difficult cancer and the whole thing is inappropriate. So it's, it's, it's my way of, of, of, of basically signaling to the correct laity. Look, this is something that can't be dealt with endoscopically. Thank you. Of course, there is one more piece of kit and endoscopy. Now, that's a full thickness resection device, which is not very infernal little piece of kit. But, but that's another story, I guess. Anyway, we'll move on, er, underwater E Mr, the new guy on the block and it's, it took me, it took me ages to understand what this was all about, but the fact is it can make removal of some polyps easier. And II got like a little graphic here for you. Let's see if this works. So if you got a polyp like that, uh, you inject underneath it, it's, it can make it more difficult because it displays it out and I got a picture here like this and all of a sudden a polyp which, which, which wasn't that big, it's not really big because it's draped over a submucosal injection. If you instead submerge it under water, it will lift it up, you know, like seaweed races under water and it makes it much easier to remove it. I got an example here from just the, the other week. So here's a polyp that looks a bit scary. Er, er, and it looks certainly like it's arising from a broad base but put it under water, you can put a snad around it and you were down to like kind of five millimeters of complete snare closure. This, this, the whole thing was in there. So when we cut it off is that defect is way smaller than you expected to be if I, er, that, that would have been probably 23 times bigger. And of course, the other time with an underwater, er, polypectomy could work well is when you have a AAA sigmoid, for example, where there, it's a bit polyp and it's lying on an awkward side. You just can't get your snare around it, get it floating a bit and it's, then it's much easier to put your place, your snare around it personally. I don't think II under water enough. Really? You know. Yeah. Sorry Katie. Do you need to change the dia settings? No, but be prepared for the fact that the dim it takes longer to cut through it just, it's just something that, you know, I have a question. Is it a misnomer when we say under water? Because we use Saline? I don't know what you use. Oh yeah. No. Saline is better, you know. That's, yeah. The reason, the reason why Saline is better is because if, if you're doing a, you know, something that takes a bit of time, all that water, of course, gets absorbed and you can potentially overload the patient with a lot of water. If it's, if it's Saline, you're not gonna get any, any sodium shifts and stuff. So Saline is probably better and it probably conducts electricity a bit better too. So with this, there was just watery water kind of water from the water pump, water jet. Uh the diaphragm, it takes probably 30% longer, which can be a bit disconcerting. But the other time when, when it takes longer to cut through is when you got, when you got muscle in the scenario, of course. Um, and then, and that's a, that's a, that's a time to stop. In fact, you might not notice this, but if you step on the dia pedal for more than 20 seconds, it cuts out and, uh, and that's probably the right time to bail and, and, and not press on it again. ESD then when you use the est. Well, I think an ESD is right for suspicious lesions, er, bigger than 3030 millimeters. Three centimeters. Why? Three centimeters? Because my biggest flat band sna is, is three centimeters across. So anything anything up to three centimeters? Hell, I can remove that M block. I don't need ESD that can come out en block er er under my watch and under your watch too. Er flat LST NG lesions er bigger than bigger than three centimeters. Yep. They always lift very, very, very poorly and, and you need it same with um er colitis, flat lesions in colitis again, always lift very poorly. And a flat band scenario is a Godsend or a or you might have, if it's bigger than th 30 millimeters, you might have to ESD it very large sessile polyps. And here that, that drawing there on the right hand side illustrates this. So this thing you, you know, you could put the snat around it. But of course, what can then happen is that you get the m, the whole cirrhosa inside the snare, er, you know, something's going wrong because you put the snat around it. You, you cut after 20 seconds, the machine cuts out and, and they got a choice and I made this choice but, you know, all the mistakes you could possibly make guys, I've made, II have stepped on that pedal again. And what then happens is that uh you get the whole thing off or you end up with a hole in the middle and, and more often than not, you've got a hole in the middle for a malignant polyp. And I've had a histologist, pathologist currently saying, well, Doctor Ramb and you removed this T two colorectal cancer very well. The cirrhosis is clear of tumor and, um, but we're not sure about the nodal state. You got a dry sense of humor in the leads and, and, and that's not in a position you want to be. So, of course, with an ESD, you can tunnel into this. When you, when you, when you encounter the, the fibrosis, you can either then bail or you can kind of tunnel up and try to kind of dissect above the fibrosis and do it in a more kind of organized fashion. Um The other thing you can do with these is pick off these vessels one by one, which is nice, isn't it? When you start off doing pect now, bleeding scares you. And I tried to reassure my, my registrar saying, look, all bleeding stops eventually. Don't worry about it, it will stop. But, you know, nevertheless, it's disconcerting, especially we've got three or four vessels all squirting in different directions and, and the whole thing looks, looks, looks terrible. Um, but of course, with ESD, you can pick these vessels off one by one and before you, even before they even start bleeding because you can see them. Er, so I think there's a strong argument for removing C all CSA lesions by ESD. Er, we talk about flat lesions in ASD, but I think cessile lesion is the big, the big area. Um and the other, the, the fourth thing, large lesions in the ascending colon because my worry about large lesion in the ascending colon is, is not removing them. I can do that. It's retrieving the fragments, those infernal rof nets, you know, you, you, you grab hole, you might have, you might have five bits if you're really lucky. But by the time you get to the rectum, you've got two bits and the rest are kind of elsewhere in the colon that slipped out of the, the blood and net on the way out. And now you've got, you got 25% of the polyp. Well, is that represented at 25% or, or did you leave the one with, with cancer behind? Well, do you feel lucky? You turn to the patient and say, look, I really like to go back in with a scope and, and have a look at your, you know, and they'll say, look, doc I've had enough. Um I'm really full of air. I feel really uncomfortable. I'd rather you didn't thank you very much and, and you can't, you can't remove all the pieces. So there's a, there's an argument for removing large sessile, large lesions. There's gonna be a piece section in the ascending column because you then can grab hold of that single piece and remove it. And of course, that will never happen, Katie for the simple reason that the guys that do ESD, they don't want to do the difficult stuff. Do they, they want to do the, the EC E sds, the one that I can remove with, with my snare anyway in the rectum. That's what they want to do. They don't want, they're not in the, in the territory, removing a, a six centimeter flat lesion and they send the colon draped over a fall. No, thank you very much. They don't want to do that. Uh They, they will, they will bail but is a problem with PME re section. They sending colon, you don't get all the fragments. Some often don't get all the fragments and then it leaves you me, it leaves me worrying that I II retrieve the, the, the, the salient bits kind of thing. Um, k, you asked me a little bit about, um, er, about diathermy. Er, the three things. Well, there's probably four things but the 33 main things that goes into the, you know, um, pre preventing bleeding is the closing of the snare. If you, if you fast you get less, less heating powder onto the polyp and you get more bleeding. Uh, the second thing I should mention is the snare, the thicker the bra the the more heater it it applies to the vessels and the less bleeding you get. And the third thing is the power setting. You mean you asked me about the power setting and basically the the the the the easy way to remember the power is that of course, the yellow side on the left there is not actually pure cut really. It's got, it's got a little bit of coagulation in there too. But if you want to go as pure cut as you can, I, what I do what I use for SS LSI would use the effect level one. So that's, that's very little uh coagulation in there. Er And then effect level two is more coagulation, 34, more coagulation. If you then start to cut on the blue side, it kind of continues. Effect level four on the blue side, you got almost all is coagulation. And in fact, I when I do a polyp er an Mr O Polypectomy, I usually use the the endocut setting yeah, effect level 203 or one if it's an SSL for the, for the polyp. But on the blue side, I put the dither on soft um effect level 80 because that is what I can use to uh coagulate in the little vessels using the coagulation forceps. I'm a cheap skate gi use the coagulation forceps 8 lb 95 and I don't use the coa grasps that retails turn 50 quid. Why would I, the coagulation forcep, you know, the Hot Ps of Force. It works just as well. I wouldn't dream of removing a polyp with the, uh, with the, um, hot pip of force. We kind of banned from doing that, but I would so deal with little vessels using the, er, coagulation forceps. The, um, the, there is a new, there's a new piece of kit. Pentax's got a, a, um, a, a heme of forceps, I think they call them where it's plus, er, on one side, minus on the other and you're close then, then the kind of the short between the two kind of parts of the, of the forceps and they say it imparts less heat onto the deeper tissues. That might be the case. But whenever I use, um, a, um, a hot biopsy forceps, I always put clips on afterwards just in case I burned a little bit too much. Um, and, you know, belts and braces if you bled bled enough to kind of deal with by coagulation forceps or a hot by the for coagulation graspers, then, you know, you dealt with the immediate bleeding, but you've got nothing done. Probably, maybe not enough to delay or to prevent a late bleed. Hence the clips. So I put clips on more or less anything apart from, um, cold snare things in patients who are not on blood thinners and even put them on clips on there. Sometimes. I mean, it shows if, if nothing else it shows a bit of goodwill, doesn't it that you really want to? And I always tell the patients, look, this, this clip is 100 lbs, you know, George, I'll, I'll sparing no expenses here for you and I want them back polished in a pot. Thank you very much when you see them passing in in three or four weeks. Uh No, I don't tell them that but uh but I do tell them that, but then I'll tell them, you said so just to kind of go to the back of life anything. So we spoke earlier about pedunculated polyps. So you said about having a mix of cut and coag so blue and yellow um For, if you're doing aci call it for an E Mr Yeah. Which one do you use? Uh So, so yeah, I would remove that like any punc polyp and it, so I'll put the, I'll um I'll, I'll choose, I, I'll raise it. Of course, I'll put the, the, the the snap, which is kind of appropriate for the polypectomy side. If it's a 50 millimeter polyp, I'll put a 50 millimeter snap. If it's 25 I put the 25 millimeters bigger. I put a 30 if it's even bigger than that, then, er, then you're talking piecemeal, of course. So I will put a spa around it. I put an effect level three because there would be big vessels underneath that se underneath that sessile polyp and I would cut on uh yeah, effect level three. And then the machine itself will set the power level according to the and, and I'll tell the nurse to come up close fast to start with and then slow down. It will generally use a cutting. Yeah. Absolutely. Absolutely. Yeah. I don't, I wouldn't cut on blue. The problem with capping on blue is that it doesn't actually vaporize the tissue. So the cutting takes an extraordinary length of time. It cooks the lesions when it comes out, the, the pathologist will be crying over the microscope because we can't make head and tail of this at all. You're cooked at the Smith do deep margin, I'm afraid is a cooked margin. There is no margin, it's fried. And, and furthermore, there's a big risk of course, of, of post polypectomy syndrome because you basically cook the whole wall of the colon. So you can't cut on blue. And the other thing to mention, you know, is that when you first step on the pedal for the first kind of half second. It's apparently it's, it's virtually your cut that the machine puts in. So, um, the ESD boys, they used to kind of tap the pedal just to get pure cut, you know, for the quick discectomy. Then they will slow down when they come out to a, but we don't do that. Our E Mr guys, we step on the, on the pedal and we keep the foot on the pedal. Let the machine do the magic. Yeah. And there's another question about they don't have any kind of fancy settings in their unit. Um So what do they do? And I guess that's, you haven't got any fancy settings. What do you mean they haven't got in a fancy settings and most people just know left or right. So, so you've kind of gone through the effects for? Yeah. Yeah. Yeah. No. So you'll, you'll, you'll have these settings, you see? Um So I've gone back here. Can you see that? I've gone back a slide. Yeah. So, so the auto auto cat, that's what herb calls it. Olympus bless their souls. They call it pure cat. Why can't they, you know, decide on a common? Amen. Hell, I don't know. They done it for the blue side. Spray coag soft coag false coag, but they just can't decide on what calling the, the kind of the cat side. So the auto cut the pure cut they on the whole, you would only use that for sphincterotomy stuff like that where, where there's no vest, you don't anticipate that and you want to cut quick. So I would, I would cut, II would make sure and your machine will be set at end of cut or endo cut queue. Why is it called endo cut queue? Because the queue looks a bit like a snare. Apparently that's how herb decided on it. Would you believe it? Uh I wouldn't, I wouldn't use the, the dry cut or the pul pulse cut. Er, because again, it's, it's a sphincterotomy kind of thing really where it kind of pauses to kind of control the cut. So you don't get sipping. Instead. What I will do change is the effect level 123 and four, which you can change in on, on your machines, effect the 123 and four, poke around with it and you'll see how to do it. So I will, I will eyeball the polyp and I will change the, I will leave it on, on Endo AQ and I will change the effect level to 123 or four. If I think, oh Christ, this will have some big vessels in it. I'll, I'll beef it up to effect level four. If I think this is a thin SSL there's no vessels at all. I'll leave it on effect level one. But for the most part, the blue side, the blue side is always at soft coag effect level to power setting 80 watts. So I can use the hot pipes or forceps to deal with that bleeding. Yeah. But for the most part, they're kind of set up with left and right setting and they're very clever. Yeah. Yeah, I, absolutely. The, the algorithm inside will kind of measure how much, how much power to put through. So you can't actually set the, the voltage level on the yellow side because the machine will do that for you. Um Absolutely. So you can, and you can trust that it, it kind of work as well as, as anything really. Although there was a debacle. K, you haven't been at the game for long enough. But when the new herb came out or, or the, the herb before the current herb, there was AAA G a great kerfuffle because there were quite a few immediate bleeds and people could not understand it. It turns out that the herb guys had actually changed the algorithms because they realized our first, our first um dither machine, er, from 30 years ago when it was envisaged, people were thin. Now they're a hell of a lot fatter. So we need to tweak the settings and put more power through it because these, you know, they're two stones heavier than they used to be, you know, in 1975. Er, er, we better do something about that because it's taking too long to cut through and of course, endoscopies weren't told of this. They are so bloody hell that went, went too quick and, and it took a little while to kind of adjust to the new, to the new hidden cutting algorithm inside the machine. Er, but yeah, that's a by the, by really. So, going on to the next slide, what is, er, which is the most important factor is actually your assistant um closing the snare the slower she he or she is, you know, the more heat you apply um in some units. By the way, the uh the endoscopist insist on, on closing the, the, the, the snare handle and uh stint Mark's hospital been always been a great advocate for that saying there you got kind of control. I find to my alarm that I'm, I'm probably more likely to, to kind of cheese via the last bit and get immediate bleeding. So, so leads we get the nurse to do it. And also my hands are usually for usually what happens is that I got my left hand on the wheels and a nurse is holding onto the shaft of the scope to kind of stabilize it. My, my right hand is on the, is on the snare by the biopsy bung and then the, another nurse is closing the snare, that's usually the set up. The power setting is the second most important the, the contact I ie the thickness of the grade of your, the thinner, the, the thinner the braid, the quicker it cuts and the, and the, the less it kinda cook the vessels. And of course, the here lies a little problem, you know, guys, because if you think about it, if you got a really, really big snare, er, a, a big polyp, er, and, er, this, er, cook makes a six centimeter snare which by necessity they have to make very thin. Otherwise the darn thing won't cut through the polyp at all. It will take forever and of course it does then cut pretty sharp and you get a lot of bleeding with that device. Er, but there is a six centimeter snare, er, for, for brave brave souls, um, tissue properties ie if you got, if you got muscle appropriate inside the snare or you've got fibrosis, it slows down the cutting and, and if you get the machine cutting out and you still have the cut through my advisor bail out and say, look this, I can't remove this. Er, of course, you, if you eyeball the patient and say, look, he is, he is, he is 85 he's not fit for a haircut. The surgeons, there's no way they're gonna take him to theater, then you might, you might toy with the idea of kind of removing it in little bits piecemeal but you know that's up to you is not working. Uh well, if it's not working, you step on the pedal, nothing is coming through. Has your assistant connected the handle, the wi on the handle. And remarkably, there is no warning that they haven't done that. So there's nothing on the machine to say beep, beep. You haven't connected the, the, the, the, the cable idiot, you know. So I always glance at the, at my assistant. Have they collected the handle before I step on the pedal? The little routine I have is the return pad on the machine will, will be with the return pad. You know, the sticker pad isn't on, have you bitten too big a bite? Is it too much tissue in the snare and you cut for 20 seconds and nothing is happening. Er, Bale, er, has the foot pedal been a sign? Sometimes you go between a PC and, and, and, um, cutting, you might have to re the, the, the, the foot pedal kind of moves around in the settings. You might have to reassign it. It's a bit of a pain. Uh, and you might find that you're still in the Argon mode when you're now back to snare again. So those are the kind of things to go through if, if it doesn't seem to be working some pitfalls. Which to be honest, I don't really worry about. One is I have got a bit of AAA fold behind the polyp and the blind side of the polyp that I can't see. And that's indeed is the reason why your n why your nurse is marking the snare handle, er, before she gives you the snare because if she closes the snare, she's not up to the mark yet. You may have too much tissue in the, in the snare open again and re, you know, recapture. And hopefully you, you, that bit of fold that you got beyond on your blind side of the poly kind of slips out, er, the other thing and I don't worry about this. You caught the, the polyp a little bit too high up and of course, the, the heat will focus on the narrowest part in the site in the, in the circuit, so to speak, which might be further down the polyp and you might find your alarm that the, the stalk is cutting through below the net. Don't worry about that. You know, it's cut through, it's done the job. That's a bit. So I don't worry about that at all. And then I put a clip on just in case the heat disturbed a little bit too much onto the, onto the mucosa and deeper tissues. The other thing which I don't worry about is a big polyp with the, the, the top that on the vap. So the polyp is resting against the mucosa somewhere else about getting a contralateral burn years ago. They used to say, look wiggle the wiggle, the snares, you cut in the tight sigmoid and then at least if it's short circuits, the tip of the, the, the tip of the head of the polyp short circuits to different places and you don't get AAA big burn. But what I then find is that instead I get a burn when the, the, the tip of the snare impacts kind of beyond the polyp stalk. So I don't jiggle it now. And if, if, if there is a burn somewhere else, I put a clip on it, uh, they're cheap on, They actually we pay 30 30 lbs a clip. Er, and er, that's well worth it for peace of mind. Rambo's rule number six, you will never regret putting another clip on, but you might regret not, not putting any clips on. So finally, Katie, when do you bought and said, oh no, this is too hard flat lesion in the colitic segment. Past the black guys, there are a pain and often inappropriate, you know, according to the B SG guy last say, yeah, yeah. If you could remove it, that's fine. And this lesion is in, is in a colic segment. This guy, this ii removed this ascending colon. A year later. He's got a cancer in this transverse colon. And then they come back to say to me, he said, Doctor Rem, you missed the cancer, didn't you flipping eck. My job was to remove the polyp. They send in cola not to do a diagnostic procedure. God damn it. You know, it's not my fault. These patients, if they got a flat lesion. I call them DDA ll dysplasia, associated lesion or mass. His, the pathologist hate that expression because we can't confirm it. Well, to me is an endoscopic diagnosis. It implies a high risk of developing cancer either within the flat lesion or elsewhere in the colon. They got an unstable colon is a ticking time bomb and, and the bail tell the patient look, you've probably got a 10% risk of getting cancer in the next 56 years. I think you should have a colectomy. Uh You know, to be on the safe side. Uh And in inevitably, they'll say no, thank you very much. Just go ahead and remove it. I'll take my chances for yearly surveillance and then after a few years, the default, a yearly surveillance and then they get cancer. Um So I got the greater respect for, for flat lesions in the col segment uh is a, it's, it's a tiger country guys. Patient discomfort, as I mentioned. Yeah. IB before I kind of and, and rebook it under a G A scope is unstable, makes life difficult. And it comes a point when basically, you can't remove things because it's too unstable. Incidentally, guys in the ascending Coron, as we piece meal, moving some flat lesion, you'll find as time presses on that, the lesion moves further and further away from you. That's not because you're slipping back. It's because with the air insufflation, you're pushing the cecum away from you. So the way they can bring the lesion back to you is to suck air out, don't push it and suck air out lesion at 12 o'clock. And you just can't, you can't move it kind of six o'clock, which is, you know, the easy place to remove it. Well, then is a, that's a, that's, that's a bona fide a reason, a reason for bailing out in, in which case, the, the, the, the patient will come to me. Probably. Not only is it difficult to, to remove it in 12 o'clock, it's even harder to put clips on if you put a, if your, if your perforator is bleeding or something. So that, that's, uh, bo had a reason for bailing and passing the buck if the lesion looks suspicious and doesn't lift a bail, this is probably cancer guys. I can't remove it all over to colorectal, but the guy is not fit. Well, if it's not fit, why did you send him for a colonoscopy? Then if you didn't think that you could kind of face the music, if, um, if the lesion is cancer, if you didn't want to find a cancer, why did you look for a cancer? You know, it's easy to say this with a retrospect, but the number of patients that are sent for investigations which don't reflect, you can't really act them because they're not fit enough. It's, it's staggering really. But then again, we shouldn't have a, an ageist policy in the NHS. It's one of my, my bug bands. Of course, we should have an ageist body. We, we've got a responsibility to take age into account for goodness sake. Otherwise we do ridiculous things to patients who stand very little to the benefit and, and everything to lose. Uh Oh Anna mentions lesions still not through, cut through after 20 seconds. Bail. Finally, I don't know if you've heard of the chaos theory. The chaos series is basically a butterfly flaps swing in Australia and you get a tornado in America. Why is that one causes the other? But how, how because of kind of, there's too many variables to tell and, and polyp, there are loads of variables and I, and I got a few kind of um er listed here. You know, there's so many variables and they all interplay. Um and I have the, the outcome can be unpredictable. It doesn't mean that you're a bad endoscopist necessarily or anything. But you know, sometimes it goes wrong and it's one of the first lessons as an endoscopy fellow in Leeds says, yeah, sometimes it bleeds. Sometimes you perforate what you need to do. What you're training with me to do is to learn how to deal with things when they do go wrong, but be prepared have systems in place for the, for the foreseeable unforeseen and of course what you need to do, you need to have a, you need to have proper consent. Of course, uh list the risks of late bleeding and perforation. If, if, if that 97 year old guy is coming back to me, I gonna list a risk of death, one in 50 to 1 in 100 for, for him. I think he, you know, a pp blood loss might be enough to polish him off. Er, so consent need to be in place, er, discussion in place consent. And, and also the other thing I do is I is II give each patient an information leaflet personal to him, detailing the signs, er, er, of significantly problems, you know, red blood on the toilet paper. You don't need to worry about blood clots, phone an ambulance to take you to the hospital, uh severe pain, er, after the uh you know, in the days after the procedure, phone an ambulance to take you to hospital, you might have a late perforation. Uh and II almost always give not just the telephone number of the unit but my own mobile number for these things and I hardly ever get any nuisance calls. People are respectful, you know, in the private setting, it is different and many, many parts of the, of the world outside. If the patient got your mobile number, you're their bitch and you, they will phone you any time. But in the UK, people are decent, they're respectful, they will phone you if they're worried and, and then you want to be phone. Of course, you, you can kind of steer them in the right direction and if someone comes in and it comes to nothing, I always praise and said you did the right thing. Don't, you know, don't take your chance that you, you did. Absolutely the right thing. You got to stay at the hospital, you got to checked out, there was nothing going on really doesn't matter, you know, better be safe than sorry. And, and that's it. We're only five minutes late, Katie. That was brilliant. Thank you doctor back in. Um There was just a couple of mop up questions if that's OK. Um Snare sizes. So how do you decide the right snare size? II bought the polyp and then choose a snare that fits that polyp. Yeah. There are some units you located where they got like one snare and that's like a, like a carpenter given one screwdriver in the toolbox. For goodness sake. You need a, you need a selection. You, you need size selection and you need stiffness selection. And so, yeah, so my toolbox is a shame. I got some here actually, but of course my camera doesn't work back on. Let me try again. I can't really, it's integral to, to my, on the bottom of the screen. Uh uh uh oh You mean on um Metal? Yeah. Try again. No, we still don't have it. Yeah, it's kind of dead. It is 15 years old. This computer, Katie. So maybe it's about time I II move on onto my laptop. Maybe. Anyway. So, yeah. So you want a cold snap. And I recommend the med works. Cross zero, excellent metal sheet. It thin wire, it cuts through things 10 millimeters, 12 millimeters as a single bit. No problem at all. It's the most powerful cold ner. And then all the way up to the flat band, 30 millimeter flat band s now for really difficult polyps that don't want lift. And often you say the size of the snare is governed by the biggest bit of the polyp. So say you've got a pedunculated polyp. You want the smallest snare that will fit over the polyp. Yes. Is that? Yeah. Exactly. Exactly. But sometimes you get it wrong. You know, you find, oh gosh, this is, I'm really struggling to get the snare over the head of this polyp. Well, then, you know, you choose a bigger one and, and try again, it, it, it, it is better than struggling trying to squeeze, squeeze that squidgy polyp through a little too tight now, basically. Yeah. And then there's just a few little questions that I have always found whilst training about what makes polypectomy difficult and if people need to leave, that's fine, we'll just ask these questions for the purpose of people that might want to watch on the catch up um, stuff like you spoke about putting the polyp down to six. If possible. What's the rationale for that. Have you explained to us why it's easier to do it at six o'clock? Oh, yeah. The simple reason for that is that your, your biopsy forceps comes out at about six o'clock. So you've got a straight line, you know, kind of working across your visual field. Of course, I remove all my left sided polyps with a gastroscope and then the, the, the, the bars comes out at seven o'clock. So for a gastroscope, you, you want the pole a little bit further towards the left kind of thing, seven o'clock. But that's the reason. And then another question we've got is about tip control and a bit about practicing it. So we were talking before the meeting started about, um, how far out of the channel to have your instruments. Yes. How far, you know, I think that helps a lot with tip control. Any other tips that, yeah. Yeah, a begin issue is usually that they're working too far away from themselves. So they kind of, they're in the distance a little bit, they're uncomfortably far away. You, you be quite close up and personal, everything works better and you be closer, the clips go firmer onto the tissues than if you're kind of 32 inches away. Um, but the other thing is I can see with endoscopy fellow start in leeds is that, you know, they, they often let go of the Shafter there of the, of the colonoscope. Grab hold of the wheel and then turn it and then you can see them looking at surprise at the screen. Oh, the tip is doing that, you know, they, they can't predict what, what happens if they turn the wheels and that's something you just have to practice. You know. So, and then it becomes, you know, it's like, it's like changing, driving in traffic. You don't, you know, once you're a bit, a bit more practiced, you don't need to really think about it. You, you done kind of automatically, you don't need to kind of look down. Where's the gear stick? Where's the clutch? Let's push that in and kind of um seize like that. It's automatic and that's the level you need to get up and you get that with practice. Yeah. And then um one kind of like final thing to summarize if you have in your head, a little algorithm for polyps. So if you have polyps under, you said 10 to 12 millimeters. If they look completely benign, what's your go to method to resect? So, I, if I think it's adenomatous uh or, or, or ssl to be honest, if it's, if it's up to 10 millimeters, I'll probably cold snare, then it's quick and easy. I can suck them up in the biopsy in the channel. Uh Sometimes you get a bit of a macerated specimen, but if it looks entirely benign, I'm not worried about it, then that's OK. If it looks the slightest bit or a slightly bit odd. You got a little bit of central depression, anything really that looks a bit unusual. The cri pattern you don't recognize, er, it and then, you know, you remove it as a single fragment, then ped anky polyps are called hot snare. You could probably go snare them. But you know that big head on ap ankle needs a good blood supply to survive. So there would be a chunk of vessel in there somewhere. Great. Well, um we've got a few other little questions, a bit about dual channel endoscopes for Mr but not something I've come across. I don't know whether you've Yeah. No, they're fantastic. I love dual channel endoscopes. The they make them both in the colon and the and in the stomach and, but they stop manufacturing them. It's the kind of the 260 generation scope in the, the picture quality takes a bit of a downturn. But what you can do, which is the advantage you can, you can use a combination of a grasping forceps and a snare. It's immensely powerful. So what you then do you put the snare out at the end down one channel, open the snare and then through the other channel, you put the grasping forceps, you grab hold of the lesion, you want to remove with the grasping forcep and actually physically pull it within the snare. It's absolutely awesome. I love it. Sadly, we, we rarely use it now because our um our 260 scope has, has broken and, and Olympus won't repair it anymore. Sadly, and they don't, don't planning to make it. It was never a big seller. So they don't want to, you know, produce a new one for the, for the one night generation. Great. Well, um I think we'll stop there because um we've run over time a little bit. Um I'd like to say a big thank you, Doctor Beckham for your time this evening. We really appreciate it and we shall make sure this is all uploaded to me. If anyone wants to watch it on the catch up. Yeah, I'll listen rather it's going to be more like a podcast, isn't it at the end of it, podcast with, with slides? Yeah, great. And thank you very much for joining us tonight and that's a pleasure. Thanks for listening guys. Bye bye bye bye.