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So um we should be live now. So good evening. Um Everybody that's joined us so far. Um My name is Katie. I'm the Endoscopy Representative for the Dukes Club and I'm also an Endoscopy research fellow in Portsmouth. So, um the Dukes Club have organized this um fundamentals of Colonoscopy webinar series, which is running over the next three weeks. Um And each week we're aiming to build on some fundamental skills that we think that we should have as endoscopist. So, um we're really lucky tonight to have an amazing speaker and um an amazing coa with me. Um So without further ado, I'll introduce them both. So my co chair tonight is Katie Eden. Um She's a consultant colorectal surgeon in North Devon and she's also the Colonoscopy subcommittee chair for ACP GBI. And our speaker tonight is John Anderson, who's a consultant gastroenterologist in Gloucester and he has held many training roles. Um He was the previous National Endoscopy Training lead and chairman of the bowel Cancer Screening Accreditation Committee and he's currently the Director of Gloucester Training Academy and is founder of geeks, which many of you have heard of. Um So I've heard doctor Anderson talk many times over the last few years and I mean, when I say he's one of my favorite speakers. Um, so I think we're in for a really great talk tonight. Um, so I'll pass you over to him and, um, he will get started with a session. Um, just a bit of housekeeping. Um, we're very happy to take questions as we go along. So, um, if you do have them, please post them in the chat or in the Q and A and we'll ask them as we go along and then we'll also have a session at the end um to have answer any round up questions. So thank you, Doctor Emerson Katie. Thank you very much. Uh I want to thank you and the Gates uh for uh not Gits Dukes for inviting me to speak tonight and I'll just bring up my slides and just check that you can see that. Ok. Yeah. Ok. So uh colonoscopy technique, um This is what I'm gonna do tonight. I'm going to talk a little bit about how you change what you do or improve your skills and then basically focus on the technical issues about intubation, which I think people probably have most er, difficulties with. I'm gonna give you some examples of some difficult cases and how you might deal with them and scatter through. I've got one or two videos to show and then hopefully we will finish sufficiently quickly enough to take some questions at the end. So this is a skills acquisition curve. If you want to put on the left hand side, your K PS, if you, if you want to think it like that, although when you're training, that's not the case, but it certainly is after you become competent and independent and you can follow roughly one of these three lines. Uh, you can choose yourself which one you are. Um, you can just get over the line and keep going and perfectly fine and a perfectly reasonable service. Some people seem to be able to continually improve themselves and others find it a bit of a struggle and meander along and, you know, occasionally go under the line for what is deemed competence. Um And really what we want to do is we want to be in a position where you are comfortable with your technique and therefore the patient is usually comfortable and that makes you competent and ideally you want to be on a trajectory where you continue to improve. So what would you consider to be the perfect technique? I wrote a few things down on the left hand side. These are just my thoughts, you can think about them and add them, add to them. Um But I think you should be calm and controlled. Being proactive is very important and I'll discuss what that is and have some logical problem solving capabilities and whatever you do, you should be able to reproduce on each others, otherwise your skills will be wasted. Um So you need to think about what that technique looks like, what is optimal. Um And I'm gonna try and touch you a little bit on that at the moment. So the first thing is to think, well, do I need to change some of you might, some of you might not, are you willing to change? And are you prepared to learn something new? Which is probably already in your comp and you already feel you do? Ok. And truthfully if you're learning something again, you're gonna have a dip in your performance to ultimately get better. Um This is an important concept because what happens is you're over the line, someone shows you something new and you go back down and you think, oh, I'm gonna go back to my old self, right? And you'll just continue on the yellow line. If you stick with it and master it, you'll ultimately become better. And it's a case of whether you want to be competent or better than competent and what internal motivation you have to do that. Obviously, that requires a training intervention and therefore you've got to know where you get this training from. So colonoscopy technique is largely divided into three areas. There's the insertion phase, there's the withdrawal phase which predominantly is lesion recognition and then there's management and pathology in today's arena that's mainly polypectomy. I know you've got a series of lectures dealing with this. And the question is, is your technique the same as everyone else, do you know that? Um are you slightly different? How will you ever know? Um And the other thing to think about when you're thinking of the three phases is what are you trained to do? So you've got insertion lesion recognition polypectomy. Um And when you're confident in getting to the, see if they just bail you at that point in time, you know what happens, for example, to your lesion recognition skills. They haven't quite, they're not quite as good as your insertion skills maybe. And of course, your polypectomy skills are even lower. So I need, you need to think about how your training progresses and what you think is complete training. And I would suggest to you now to be complete in your colonoscopy technique, you should really be trained and capable of dealing not only with insertion and withdrawal, but also dealing with level two polypectomy. For tonight, I'm gonna focus mainly on insertion. I'm gonna to touch a little bit on withdrawal cos it's the two things are linked and I'm gonna leave the pathology management to other speakers that follow me on. So if you think about what things make colonoscopy difficult. Um Well, firstly, there's a basic knowledge that you need this basic technique that you need. There are some technical aids you can use. There are patient factors which people tend to blame when they're struggling to get round and then there's some specific problem solving things that you need to apply when you're struggling. So if you haven't got the knowledge or the basic skills, that is your problem. Technical aids, we can talk about patient factors, some are predictable and some are not. And it actually, if the patient is coming for a second time, most of the problem areas should have been documented by the previous endoscopist. And you can learn from that in terms of having specific problem solving algorithms. And this is rather than just applying a random solution, you need to be something called consciously competent in your colonoscopy. And that is you have to understand what you're doing and why you're doing something and what the expected consequence of that or result of that is to enable you to overcome the problems you come. And I would encourage you all to try and develop conscious components of colonoscopy. Um So I think you have the responsibility to develop the theoretical knowledge and I'll touch on some of that today and I apologize if this is sort of reviewing stuff you already know, but it's so basic and so fundamental to what we do and you don't have to be scoping to have this knowledge. Er Kate, you very kindly mentioned geeks at the beginning and there are other resources available to you to enable you to actually learn quite a lot of stuff before you pick up a scope. Um my colleague, Roland B gets quite frustrated with people who turn up for polypectomy training day, who can't actually describe a polyp and they expect them to start, you know, day one to walk into the room and that's not the case. Um And your understanding of very basic principles and for as surgeons, I would applaud you because you understand a not anatomy, colonic attachments and therefore understanding the effect of gravity on, on the bowel and fluid and air and colonoscopes should actually not be a great leap for you. Cos you're just applying what you see on a daily basis. So I think you need to have some fundamental understanding and then that allows you to be something called proactive and by proactive, I mean that you do something to prevent a problem rather than having a problem then solving a problem in saying that you need to solve problems that you can't prevent them all. But you, but ideally you would be proactive and that allows you to insert quicker and more comfortable, we'll talk about pressure. So in terms of the knowledge core that has to be anatomy, gravity, fluid, and air scope, handling, scopes, accessory, et cetera, you can read this thing. Um So what am I gonna cover tonight? I'm gonna cover some basic techniques, facilitated torque, steering is probably the key one and that is where you move the instrument. So you're inserting the instrument and to the instrument and then simultaneously moving the tip of the instrument up, down, left, right, or in a combination to enable you to, to precisely put the tip where you want to go. I wanted to do something called pleating where you plete the colon on the shaft of the colonoscope to keep everything straight. And I want to introduce the concept that if you've got resistance at the tip, you're more likely to cause a pressure in the scope itself. And that will ultimately lead to what I call a buckle and then you'll form AAA loop and once you've got loop, you're obviously gonna cause discomfort and lack of er progression. Um And interestingly, the really good people don't hardly seem to be moving the scope at all. There barely seem to be uncertain. It, it seems to end up with the cup. Everything's done really slowly. The movements are really small and it's controlled and the people who are thrashing and effectively trying to play a trombone tend to have loads of problems. So please do not be a trombone player, just be calm and, and nice and slow and logical movement. And if you have logical progression, you're likely to be a much better scope. And when you have a problem, you need to be able to deconstruct the problem and then formulate the solution and ultimately, you're trying to get a straight scope most of the time. I appreciate you understand the concept of how you do it. So I want you to think about the problems you're having this way. What is the problem you're having? Is it because you can't see, is it because the patient's in pain? Is it because the school feels horrible and awkward? Is it because I don't know, you can't get access to a polyp? W what is the problem? And therefore what is the logical solution? And then can I do I have the skills or the techniques to overcome that solution? And we applied this to pretty much everything in colonoscopy and, and our website on gigs we, we discs construct just about everything. So we will explain why we do something and how you do something. And when I show you the video, I've got, I've kind of got a running commentary going on the video. So I apologize. I am to monologue for like 40 minutes here. I apologize. Um But I've tried to explain what I think. Now one of the questions we get level that is, is what's an expert or what, who's the person to say this is the right technique or the wrong technique. And all I can say to you is I spent a lot of time watching people doing endoscopy and I've tried to distill everything down to basic principles and if it's easy to do and it's reproducible and it works, I will do it. If it doesn't work, I'll not do it. If there are two ways to do something, I'll work out, which is the best way to do it. Two things are the same. I want to be able to describe both techniques and the arguments pros and cons for each technique in different situations. So I apply the right solution and if you're in that position, then you're going to do very well in terms of colonoscopy you. OK. Good. OK. So um with the cap on, just gonna have a quick look in the rectum, beautifully clean, you've done very well. We have a foot pump here when we put you on, just put the foot from on. And the first thing I'm gonna do is come back to be at night, just make sure there's nothing desperately. And then we're gonna do uh and underwater incubation. So I'll just click the bottom and you'll see in the right top corner, then your focus is come on and then taking all these airways and then we're gonna go under water. So it's really important journey under under water. You take the air out. Now, I know this lady's got long call on 10, slightly bigger sport. 290 a little bit fight there. So we can, that's great. Five. We're just inserting and we're coming forward to rectal signal junction on the image you'll see it is moving anterior here. I'm just pulling back so I can see where I'm going le off. Then at seven o'clock which is angulating the tips using the wheels and a little bit of anti I torque to get into that position again, just adding a little bit of water to just stand the lumen. Not sure why it's not clear. Thanks to move again. Some Povi talk having got round that corner, I'm gonna try and straighten the cool on up a little bit. We want anti clock wise, I'm just gonna pull back a little bit. Sorry about here. Adding some water. We've got some tip angulation. So we're gonna rotate the scope and we're gonna rotate the scope. We rotate the 10th angulation from going down and I hope you rotate it. So we just take out not quite at the moment. We've got a little bit of a hockey stick. So we're gonna advance a little bit further. Nice G in. We got some light sedation. I'm gonna use the next cold. Yeah. Take the cast out and replace it with some fluid. Also lubrication and allows the scope to slide forward. OK. Top eyes and I'll bring the tip up and I'm stepping and um, and you can see as I pull back how much movement there is within the sigmoid colon. This is spinning clearly, the fluid will help wear it down. But the other thing to consider is she in her left lateral largely to keep the fluid in the left side. But it means gravity is affecting the sigmoid loops. So we're gonna pop her onto her back. So come onto your back. For me that's super and shuffle to the middle of the bed. Let's see if I can lift your right leg up. This, that, that's perfect. So this way gravity is acting more evenly on the sigmoid loop and it should give me a little bit better control. You can still use water some more in the tips following the, in the group. And the, I suppose incisions drink the fresh bit. You can see the loop configuration. This will be a big pot I fall. So as I reach the fall, I just rotate po wise and then I'm gonna start falling back. I haven't done, moved in at all. You flip the scope up on the imager, we're now facing up towards the spanning fracture. And as I pull back and aspirate, restrain the colon out, well, nice and straight out um oh out the splenic fracture. I maybe. So I'm thinking we might be, we might not be, it might be a very long sigmoid. So I'm gonna put the stick on. I'm gonna gently insert and take the focus off. We're gonna use, see a two now. It feels like it's when like. So here I've just gone past the splenic picture. I'm gonna take this off. I'm gonna aspirate the fluid, pull the scope back. I angulate the tip. I've just a little bit of I thought to align me. So I got the tip off as I move along with trans aspirate, aspirate, not moving my right hand at all on the shaft just aspirating to get a view and gently inserting. You can see we've got this deep transverse loop. So I'm just gonna pull that back, strain it up a little bit. So can you get the marker ready? Just asper? There's no rush here and bring the bed up a bit. I'll just ask my colleague to get the marker pen. So in the mid transverse here, we're gonna put some pressure just underneath the transverse and he's gonna push like this. And you'll see on the imager, this has already gone up a little bit and this should allow me to traverse the transverse fairly smoothly. I'm gonna aspirate as I do that, take the fluid out, just gently insert the instrument, aspirate, aspirate, aspirate, gently insert right up to what is the hepatic fracture again? Aspirating just aspirating. Absolutely. Then I'm rotating the cook hot wise. You see that the pressure is still on the mid transverse. We've just come to ways that have questions dislocating and I appreciate there's a lot of balls up because there's fluid and we're putting C two into the stand and get more fluid into this. So this is the hepatic culture. You can see a tattoo and that is the and we can just gently insert when we get and I'm gonna ask you to like go and then I'm gonna ask the patient to lift this leg up and roll over for me. Come on to your right side. So the beauty about having light sedation is that is very mobile on the right lateral cos this is a immediately media fecal ball, um, to see four of any fluids which is a nice do from the appendicular and then come back. What can we give her some to come? So that was just AAA an intubation I did, uh, and just chatting through it and we're gonna cover some of the things I was talking about during that procedure. I don't know how long the intubation was, but it, it doesn't take very long to get in even though the patient has a long call on. And I think you will intrinsically know this. But basically, if you're pushing in a lot, you're likely to cause pain. The reason I put this slide up is not cos you don't know that but your nausea sep your nausea section is um related to two things. It's the degree of stretch and the rate of stretch. So this means that you can stretch something quite a long way and the patient will tolerate it if you do it really slowly. But if you push in really quickly and there's a dynamic change and a large change to the stretch fiber, it tends to fire off and you get really uncomfortable. So I'm not saying that you're never gonna cause discomfort. But if you cause discomfort by pushing in really slowly rather than quickly you're going to cause less patient discomfort and you're more likely to keep control of the environment. Your heart, be precision, be precise and be, can I just ask a little question here, Doctor Anderson? So, um we saw that you were using an adult colonoscope in that one. So, acf 290 for the audience, is there anything you would suggest about when you might pick an adult colonoscope over a pediatric colonoscope? Very good question. So an adult colonoscope is thicker. Uh So if there's uh uh and it's, and it's more rigid. So if you've got a very long redundant colon with multiple loops, I would tend to use an adult colonoscope. It's kind of a paradox. You think, well, lots of loops, you want a nice thin one to go round, but that's assuming you're not taking the loops out and with an adult one, it lets you to complete the colon just as you saw in that example. So I use my adult colonoscope er for two things for long redundant colons and for doing therapy because it gives you a wider channel and you get near focused capability and you can suck the polyps up the channel. And if you want to, if you don't, if you have no way of predicting who that is, I would suggest to you that the very rotund obese patients tend to have a very redundant cola, anyone who's got chronic constipation tends to have a long redundant cola and for everyone else, it's a lottery and I've moved my position away from using P CS. And if you give me a choice of what instrument to use, I would normally use an adult thicker scope these days. Cos I think it gives you more control. Paradoxically, if you've got a very fixed sigmoid colon, you want something that's really flexible and therefore we would tend to use a PCF. And I think a lot of people are ordering P CS cos they think it's easier and it's a PCF allows you to push round loops, I think. Um, but also potentially causes you pain and it, it also will lack stability on the lesion. Um If you're on the right side of the colon, for example, and you've got an unresolvable, unresolvable loop. So I think, you know, if you're used to using a PCF, you should try ACF, you'll not like it to start with, but actually, you will find that it's really useful in certain situations. If you use C FS all the time, you've gotta remember you can use the PCF in situations where there's gonna be fixation, er, or rigidity to the call on. Is that ok? That was great. Can I ask you just one more on that? Do you use BMI at all as an indicator of when you should use A P CFI? Do my nurses know if you go for the strike, a trolley, I need a CF scope. So that's a fat scope, fat patient, fat scope, uh in general. Ok. So I'm gonna do a little bit of loops for you guys. Er, why do they form? Well? It's largely due to the anatomy. Um, but also, er, if you've peed the colon and then you put resistance at the tip, er, the colonoscope will bend, er, and it will form another loop. Um, also your technique will either aid or hinder your progression and your loop formation. So how you handle the scope and whether your productive reactive will do this, as will your air water management, as will your patient physician? And as we've just discussed, you may be more or less likely to form loops depending on which instrument you use. But generally the worst loops are formed in long redundant colons. People who've got long reason tree or the other way to go is they've had surgical intervention and often what happens is they got a long mobile colon but they've got some adhesions or they've got fixation where there's there, the sigmoid and they're unusual and that it feels really stiff and hard, but the whole thing's spinning the whole time cos there's a point of fixation and everything else is just spinning about the patient, the fix fixed part. Um I'm gonna talk a lot about patient position and sadly, er, on average female colons are definitely longer and if you're not sure about the patient, the usually the thin female has got a ridiculously long colon and I think it's, I don't know why it is, but I'm presuming it needs to be right away when the fetus gets in there. So, either ridiculously thin females or obese patients have long colons. And if you're not familiar with this piece of kit or you don't have it, this is a thing you need. This has transformed our teaching of colonoscopy and this is some form of scope tracking device, um scope guides, the one we've got and that's what I'm showing, but Pentax have got one and spooky fill up and without this, it's very difficult to be logic logical in how you resolve loops in relation to loops. I want you to think about whether they're stable or unstable. So clearly a stable loop will form and then it doesn't get any bigger. Er, and you get 1 to 1. This is a classical alpha loop. This is where you think. Oh, I've got a loop form and you go, oh, maybe I haven't cos it's moving in lovely. Now. That's, that's a stable loop. You have got a loop and you know, you've got a loop, you're just pretending you haven't got a loop and then unstable ones where you push in and you don't get 1 to 1 progression at the tip. So the tip might move forward but it doesn't move forward to the same ratio as you're inserting the scope. Uh These are classically your N loops or your N spiral loops. So let's just talk about insertion and colonic pleating. Er So your colon's got is nicely pleated already. You're just gonna add to the pleating. So this is what I call an unstable loop. So as you prog push in, what happens is your tip seems to move in a retrograde fashion. And that's simply cos you're stretching the Mery here and eventually the stretch becomes so far like you get pain. So instead of stretching, we go back and at this point here, as soon as you get to that, you go back to this and then you do something different. And what you do is you hook the mucosa, so you hook this fold here when it's got a hockey stick. So you advance to the next fold and then give some tip angulation. So instead of pushing in and giving pain, there may be some progression, but you're gonna get pain. What I'm gonna ask you to do is hook and then turn. So you pull back, you hook, then you pull back and it shortens the colon and ef effectively, it pulls this fold down a little bit. And at the same time, you rotate the scope and instead of pointing down, it will start pointing up and you will effectively flip over the loop. So what we do with torque steering is we change the anatomical configuration of usually the sigmoid colon in the bowel, but it applies in other parts of the colon and you flip it to a configuration which is favorable in progressing the skull. And I mentioned it, the video you've just seen from pointing down to pointing up. So basically, when you got a hockey stick pointing down, you need to get to a fold and you need to rotate the scope through 100 and 80 degrees. Which way when you look at the image, it should tell you if you're not, you can feel it if you're going the right way, basically, the scope is coming freer and your scope's getting longer and you should be able to pull out if you're going the wrong way and you're making the loop worse, then you will feel the scope stiffening and your scope een essentially shortening as you rotate. Um But if you can interpret the imager in three dimensions that will solve those problems. Um So usually if you've got an alpha or reverse alpha, it, which is unstable. So what's happening here is you're pushing in and the loop's getting bigger, right? And you suddenly reach a point where this is stretching a bit and the patient usually tolerates this. OK. You've got a bit of discomfort and that usually allows you to get up to the top. So because it's a nice open loop and the scope is moving, you would probably allow that to be tolerated cos that is a wide open loop, very difficult to resolve until you get some angulation at the tip. Ok. So you probably tolerate that. You'll get a little bit of discomfort, but you can warn them of that and say to them with confidence, I can reduce this. Just bear with me for a few minutes. Ok. In a stable loop, it's this situation which is your classical alpha loop where it forms, there's very little discomfort and then you can whiz up to the splenic fletcher and they don't feel anything at all. And then you can straighten it out and that's ideal, but it doesn't happen very often. OK. That's a stable loop. And what you get often is what I call an N spiral loop. So this is in two things, but it can be in three and you can do two things with these. There's a clever maneuver where you reduce the N loop and right at the end you apply torque and that's usually sufficient to overcome an end spiral loop and or failing that. And sometimes they are impossible. What you can do is you can add torque to this N loop and convert it into a nice round loop. So this will progress, this will not OK. And the solution depends on how mobile the sigmoid colon is, how much discomfort they've got. And what your technical skills are, whether you can reduce this without having to form this. This is occasionally a solution for dealing with a bad and spiral. But in general, we tend to see these, they can be open or closed and the imager will tell you which way to turn. So this bit is anterior. So this is clearly a clockwise maneuver. This is the reverse of that. This is an anticlockwise maneuver. Once you get angulation at the tip, and if you can know the imager, you will sort the problem out. So here's the N spiral. This is the one most people deal with. You've got this sort of configuration of patients in loads of pain you push in, this makes it worse. You get retrograde movement and it's just horrendous and you're never gonna get the the scope to go round like that. You will, but you'll, you really need to flatten the patient, give him all the sedation to get round. This is, this is the really uncomfortable, usually young female, right? The solution here is to engage the tip here. So a slight angulation here and then we're largely going to pull down very, very slowly. And in this case, it also applying a bit of plot wise torque and I'm going to aspirate at the same time. And as my tip moves forward, I've got to control the tip movements with my angulation, control up down, left and right to ensure that the tip does not hit the wall. If the tip hits the wall, what happens is you get resistance and you don't move forward because there's resistance. And when you don't move forward, you slip back and you fall out, then you have to put them through the pain again to get back to this point. So angulate the tip, start pulling back, aspirate, make sure the tip is maneuvered into the center of the lumen. So it's free. And at the same time you're gonna aspirate. And when you get to this point here, usually you add a little bit more torque and it goes up and it's, it's like a miracle instead of having, um, about the stiffener. Once you've reduced that kind of loop, would you, if you've struggled to reduce it? And then you've got a straight scope. Would you routinely use it or? No? Because it's more. No, I II only use a stiffener at the splenic flexure. Yeah, I only use a stiffener in the sigmoid colon. Um, because, uh, you don't know what's gonna until you get the splenic flexure, you don't know what the anatomy is. And if you've got another sigmoid loop, uh, people will put the stick on and then they start forming a loop again. They'll not bother taking it off and you're putting a lot of lateral pressure on the, on the bowel wall then. So I, yeah, so I tend to reserve the stiffer just at the splenic fracture. John, I'm interested that you've suggest or you want us to aspirate before the end has resolved completely because if you're water insufflating in the bowel is there enough air there to need to aspirate into the side wall. Right. So, if you're using water, this merely forms good. Right. Ok. Because the water will wear down this bowel. And actually there's some great studies where they've took a, a sigmoid B that's filled it with water. And the sigmoid involved undoes itself. So the weight of the water, if you're doing under water, you rarely have this position. Very, very rarely you have this position. This is usually using air intubation. So what happens is you get to here with water, you get a bit stuck, people panic, they start thrashing about, they start putting air in and everything gets distended more approximately. And then they get this really tight angulation. If you do water, you, this rarely occurs. Now, I'll not say never but rarely occurs. So water overcomes this problem. So if you're having problem with this sort of, er, end spiral loop formation and problems, you should go to underwater cos it will effectively solve itself. And what would you say to trainees who cos I've had it before where I've had, um, supervisors that something's not their practice. So they're not very keen for you to try something that's a bit different. So if you have someone training you that hasn't ever done underwater and you as a trainee want to have a go at it, what would you say to how we can convince people to let us do it? Cos I think it underwater is the way forwards. But yeah, so I think under certainly left sided intubation underwater is the new norm. Uh I appreciate some of your trainers not, might not want to do that but lots of people can. I think there are sufficient examples available for you to help you. Uh The A CPG IBI, G GBI bought lots of licenses for geeks and we go through explaining how to do it under water at some length in those videos and some of those things are free. So even if you've not got AAA license for it, you can go to the website and almost certainly you will see some demonstration videos you use under water and explain how to use it. And I would encourage you to use it in your practice. I would only have a problem with the person training. You stops you doing it. But actually, if you, if you're using water and they're not, you can teach them something, I promise you. So, er the other area we get loops is usually in the transverse colon and anatomically, you recognize this look like the transverse colon. And if you simply push in, you have a problem that the sigmoid rides up. The, the descending colon actually BS laterally, even though it's supposed to be a retro perineal structure, the splenic fracture rides up and rotates posteriorly in this angle. It, and you have this horrible situation where you get retrograde movement and you're on a really long scope and you have multiple areas of problems here. Ok. Now, if you've got a floppy scope and this is, I think where floppy scopes were designed, uh, with Propofol in the state, I don't wanna be derogatory, but essentially you can push it around to the cecum and you just have a lot of scope in a patient which is fine, you reach the cecum, that's one objective. Um But actually, if you're gonna do any therapy, you can't do therapy with lots of loops in your scope. Um And it's a little bit easier if you stop the loops from forming. So there are lots of potential issues here in a long, what I call a long scope position. And what I would encourage you to do is try and adopt a short scope position where possible and avoid the long scope position. And that means you essentially insert the instrument to the apex of the transverse. And what you're going to do is you're going to cantilever at the splenic fracture here. So what you're gonna do is hook and then pull back and you'll see as you pull back, firstly, your tip is pulled back and points the wrong way. This comes down and forms a nice straight position here. And all you have to do then is def flex the tip, right? And if you do that, you stretch there deflexed there and it looks like this and then you just progress into the right colon just as you saw on that video. Now, if necessary, uh you can put some hand pressure here and I'm gonna talk about hand pressure in a moment and hand pressure is ideal for controlling the loops to enable you to go around in what we call a short scope position. So try and do your transverse in the short scope position. Yeah, abdominal pressure, I've seen a lot er badly. Er people tend to put abdominal pressure on first. And I used to say when I was training that the reason people put abdominal pressure on is to distract the patient while they push through the loop. And that's largely because I've seen a lot of abdominal pressure which is simply ineffective. It doesn't control the loop at all. And that really shouldn't be your first port of call except for some very specific situations. And it as a rule of thumb, abdominal pressure does not work to control sigmoid loops. The Mery is so variable. If the loop is coming anterior and you think, oh, I'll just control the pressure, it'll just go laterally, it'll just spin and go somewhere else. So it has to be an anterior struct structure for the abdominal pressure to be effective. And the most anterior structure in the colon is your transverse colon. It's perfect for abdominal pressure. Um and you need a scope tracking device. So I think it's likely to be effective in two positions. So in the really obese patients, the colon tends to b laterally and in the very fat patients, what you can do is and you can try this er you with the image, it, you just put your hand between the rib cage and the pelvic brim and you push from laterally in towards the midline and you'll see the whole colon will shift right across the midline like this. And that makes the scope shorter and straighter and usually allows you to progress into the transverse colon. That's a really simple maneuver to do. Um And the other area and probably the area that's most useful is in the transverse colon. As I demonstrated in my video in the central aspect just to lift this up a little bit and then you just straighten the tip and down you go. Uh the other area is just underneath the right ribs where you've got a very long redundant colon and actually the transverse colon passes beyond where the ascending colon is. OK. So it goes laterally here and therefore you want to lift this up and you will see the difference between this, this position here where you lift it up and then you put anticlockwise torque, an anti clockwise torque will drag your splenic fletcher forward and drive your tip forward. Whereas here you lift up, you apply clockwise torque. OK. There's a difference between the two situations. So in this position, anti clock ice salt will work and in this position, clock ice to will work and it will lift the colon up and then you put pressure underneath. So we've got a question about um that probably relates to that part about um what do you do when you can see the seeking in the distance, but no matter what you do, you can't get into it. So that's probably a transverse loop. But h how do you overcome that? So the first, the first situation is put the patients with pain and applied transverse pressure, cos that's usually where the problem is. So the first thing is you insert and you've got to decide, am I blowing out in the sigmoid callon? Am I rotating the scope posteriorly at the spinning fletcher or am I causing a transverse loop or is it a combination of those things? And then you apply the solution that works for the majority of patients. If you're looking at the cecum and K and then you just roll them in the right lateral position and in the right lateral position, all the weight of this transverse colon will be pushing your scope into the cecal pole. And that's the easiest thing to do. Put them in the right lateral and sit down and you'll just go down plus or minus a little bit of pressure in the central abdominal area. So if you think about them facing you in the right lateral, I get my nurse to put her left hand on the hip and her right hand in the epigastrium because you get counter pressure, it stops the patient from rolling backwards and within the right, in the lateral, right, right lateral position, you should descend into, into the cecal pole. So speaking about rolling patients, let's think about anatomy and what gravity does. So we think it's a colon in textbooks like this, but we put them in the left lateral position. Yeah. In the left lateral position, my, my er signs are the wrong way round but there you go. Interestingly, um er in the left lateral position, gravity is on this way and all your loops are tight and angulated. Now, that is great for keeping the fluid over here and all the egg over here. So, but these are acute points, right. So if you're gonna do under water, you want them in the left lateral cos the water stays in the left lateral position and actually these points become less acute. But if you're using CO2, what, what is happening is all the fluid that's left in the colon is draining into the space you're trying to look at. So you can't see in any air you're putting in is simply inflating the right colon. So people who er insert with a patient in the left lateral, I apologize for the labeling in the left lateral position. You usually realize the reach of the transverse colon cos when they turn the corner at the splenic pressure, the transverse colon looks like a zepelin. It is absolutely enormous cos all the air they put in getting rain has tracked to the right colon. So if you're using air, I would seriously encourage you to put the patient to pine or in the right lateral. So in the right lateral position, what happens is these loops become nice and open and they're easier to navigate than, than with them tightly angulated. So we have a different position for water intubation to air intubation. So if you're doing water, you want them in the left lateral. And if you're doing air, you want them in supine or in the right lateral. OK. For this reason, yeah, the cecal pool is interesting when the callon is straight. Uh what happens is the mesenteric attachments and the natural configuration of the skull which try and straighten itself will naturally tend to push the cecal pole medially most of the time. So if the cecal pole is medial and you put the patient in there, right lateral gravity is going this way, the fluid will fill the ascending colon, but the cecal pole because it is medial will be full of air. So the right lateral is optimal, I would say eight or nine times out of 10. In fact, I would say more than nine times out of 10 or distension of the cecal pole. So you can see it properly. So in terms of, can you prevent loops. Well, not always, but you can a lot anatomy will affect this, resistant to the tip, affect this. And as I've described your technique being proactive will help. I think what is the game changer here? Um So yes, you need scope tracking devices, but I also suggest you get a water pump and you will see in most of my videos, I use a distal tip attachment. So if I'm doing therapy or I'm doing a native intubation, I will use a cap. If I'm looking for surveillance, I'll tend to use a cuff. Um You can, it works perfectly well without them. It's just, it's a little bit easier to keep yourself away from them because of um that comes just two little questions if that's ok. There was a question earlier about, do you routinely use a cap? Um Do you mind just explaining to us the difference between a cap and a cuff? Um First of all, I'll show you a picture of 10, brilliant. Uh There you go. Ok. So this is a cap strip, plastic cap and it keeps this op, it keeps this distance. Uh start they give you against the mucosa. So we tend to use it when we're doing resections and it keeps you a little bit away from the mucosa. Now, when you're doing an underwater intubation, the, the lumens closed over and you're very close to the lumen and it just gives you two millimeters to see the anomic grooves and the folds a little bit easier. So, doing underwater is easier with a cap and if I'm not sure what pathology I'm coming against, I tend to use a cap. So intubation, I tend to use a cap or nothing for surveillance. Um, we use a cuff and these are optimal during withdrawal. So as you're pulling it back, the little fingers stick out like this and hold the mucosa back, flatten the mucosa and optimize your view. So you're more likely to pick up polyps. Now, if it's er, a difficult intubation, obviously, the cuff will make the scope a little bit fatter and more difficult to insert. Um So if you've got a rigid sigmoid, a severe diverticular disease, you're probably best not using these. Um But if you haven't got that and you're doing surveillance, particularly polyp surveillance, I would encourage you to use a cuff. And if you're listening to this and you've never used ac or a cuff, I would suggest you go and try them because it will revolutionize what you do. And if you want to see an example here, uh this is er, using water intubation, which you saw on the first one, but this distends magnifies and cleans and usually is done with the, the er near focus button on. So you can see you suck out the air, you fill the fluid, you can see the folds spine, you can see instead of everything being distended everything's very close to you but the polyps simply floored up in front of you. It's, er, you don't miss very much. Um, there was also, and the annoy a question about if there's b bowel preparation and under water. So it depends what you mean by bad. If it's solid stool, you can forget it. You need to go to air. But if it's just discolored like this or some floaty beds in what you can do is do a water exchange. So you basically have your foot on the foot pump, put your water in at the same time, you're aspirating it out and it's like a washing machine and it will eventually clear if it's really bad bowel prep. You need to ask why that is, er, I appreciate it does occur. Er, and you may either want to abandon or you'd switch to air. I would encourage you to use. Um, delete, just wants to ask um, about cums and difficult cums and whether you go to prone and when you would go to prone, right. So I'm gonna cover some difficult scenarios in a second. So let's just start. So this these things make things difficult, right? Fixed sigmoid, rigid sigmoid loop, redundant colon, surgical hernias, et cetera. So, er, here is a difficult case like this is the one I presented at the B SG. This is a real case. Uh You can read it there, er, triage fit for the procedure mass in the cecum, er, previously failed, er, colonoscopy with thickened and diverticular disease has already had midazolam and tried with it out scope cos I thought I'm gonna be doing therapy. Didn't get very far. Um, tried a water intubation technique with the patient in the left lateral fix, sigmoid didn't get anywhere. Right. But we're expecting this to be a tricky procedure and we're not quite sure of all the pathology yet. So we'll see how we get on. So it can make water intubation a little bit easier because it keeps you away from the mucosa, lets you anticipate where we're going next. And that's the PCF you using now, isn't it? And we reached this point with the other scope and we couldn't get any further. So I know for a fact that this angulation is very tight. I could try with this scope to try and get round. It's got a more flexible tip. But actually because this is anterior um sort of rectal sigmoid junction going forward. Uh severe diverticular disease, believe it or not prone is the best option. You love being due. Ok. So with the patient prone, um I'm now gonna take out the gas and fill it with water and I'm generally gonna advance and I've got maximum tip angulation here. But you can see we've got a little bit of progress already gently, gently push in. You see a very tight angulation on the tip tip, Gasset, replace it with water really, very gentle pressure with the right hand, oral pressure, try to relax your head down if you can. I know there's a lot of pressure at the front there that's gonna pass off in a moment. The trick here is a combination of speed and tip ambulation. Cos torque steering is not going to work very well because it's so rigid and really G A GG, gently pushing forward. Um, I'm using the tip aggravation do. She was very, I think it'll be all right. I just need the patient's tolerance really. So, we're just gonna wait, let the drugs kick in the gas out. You noticed, I just got rid of some of the stool that was gonna be obstructing the view, it progresses and eventually you get round, but it's largely as you see on the left hand behind your. So I'll stop that. But essentially, you know, um, for this type of thing you, you need. So we're expecting this to be a tricky procedure and we're not your front there and pass off in a moment. The trick here is a combination of speed. I and so prawn, er, some additional sedation if required very slow tip steering. Um, and then when you get beyond this, you gotta try and straighten it up. It's not always possible but you, but you should. Um, and the prawn is because as you can see here, the, the scope comes anteriorly and it is completely rigid. You can try putting hand pressure just above the pubic synthesis. Um in this case, but often prone is the way to go. And if you've got a difficult polyp at the rectal sigmoid junction, again, prone is the way to go. So one of the few times I use prone, I rarely use it for the cecal pole. Um uh And then this lady uh had a resection er and I was, I think I was gonna show this so sorry. Er so fix sigmoid junction prone under water cap, thin a scope tip, steer until you get beyond the flexible area. And sometimes when you're using a very flexible scope, um the rigidity of the sigmoid colon will keep that from forming massive loops as you go into the right side, often they're not imager compatible. So I try to use a PCF where possible. So at least I've got an imager. Um Yeah. So think about it early right in the patients, you know, switch early, don't, don't, don't lose the patient. Um For long redundant colon underwater on the left colon to control the loops, put the patients pine cos, it stops the loops from moving around in gravity. It's it's a better way of doing it. Use a cap stiffen out the splenic fer and use a fat, a stiffer scope and then lateral hand pressure as we discussed, you know, in the in the lateral area on the mid thing and then for rigid sigmoidoscopy, er rigid sigmoid with, er, er, diverticular disease, which I guess you guys do a lot of looking at now, um, please treat them with antibiotics if you're gonna scope them, er, try and get on top of it. I know, I know your guidelines said antibiotics is the same as weight and weight, that's fine. But if you're gonna scope them in six weeks, give yourself a fighting chance of, of having reduced inflammation. Um, left lateral underwater cap, thinner scope tip, steering, small movements, frequent pull back and then you, you can usually get through this. Ok. And you may need an increased analgesics in these patients, particularly if they're inflamed. Um and then long colons, I think we've pretty much covered. So left lateral pressure here, pressure there. Um Yeah. Um and then there's a thing called a gamma loop which is uncommon. It's effectively a volvulus of the transverse colon. And you, this is the one where you get the scope into the, the, the, the hilt, er, and you're nowhere near the cecum. Um, you need to take out all the left sided loops and then, er, normally that's sufficient if you take out the air and keep the, you to get your scope tip to the cecum with a loop in er, reducing a gamma loop is incredibly difficult, it can be done. Um And it has to be done if you're gonna be doing therapy. Um but in essence, you end up with a ship? Ok. So if you've got any sort of looping on the left side, your scope's simply not long enough to get this. Can I um, ask another question? Um So on the basics colonoscopy course, obviously they teach that you can put loops from the scope into the umbilicus. And after we saw you do it in the first video, what's your thoughts on that? Because I find that um, some places I've worked have been told off by trainers for doing that. Um Some people don't like it. Is it something that we would encourage or? So what this is what I do, Katie, I will tolerate one loop in the umbilicus. OK. So I will frequently transfer the loop in the umbilicus. And then when you get to the mid transverse with a straight scope like this or even in the, here in the descending colon, I just retransfer the loop through the, through the instrument. So once the instrument is straight, you can take the loops out of the umbilicus back through the scope without undoing anything. If it's a really difficult procedure and I get to hear and I've got three loops in the umbilicus. I will simply ask them to unplug the instrument, take the loop set and plug it back in. But you can't have loops. If you, if you have loops, you've got to put them somewhere. So you put them into the umbellus as you put them into the Umbellus two things happen, the scope becomes relatively stiffer to handle because you've got loops in the system. Right. And the second thing is your umbilicus becomes short and starts dragging on your left hand. So I will tolerate one loop, maybe two loops if it's gonna be resolved fairly soon. But I have no qualms about putting them in the umbilicus and if necessary detaching the instrument and then reattaching it haven't took the loops out there. Who, who's to say you can't do that? There's nothing pressure. I'll tell you another another day. OK. Right. It's just crazy. I, I'm all for an easy life. John, I've got a question. Um So when you get your gamma loop and you find your polyp in the cecum, um Do you then uh take your gamma loop back out, come back to the transverse try and reinsert and, and know that you're going to get the gamma loop without putting the gamma loop. But then you normally you'll get the gamma loop back again because it's the way, potentially the way the colon is sitting. What do you do? You've got to take the gamma loop out once you've reached the second and it's done, this is a massive anticlockwise. So gamma loops can form two ways they can form with AAA that requires anticlockwise to effectively you fold this part of the colon down and straighten or they can form the other way and the other way you can't resolve them OK, because you've got nowhere to go with your all. But the, the, the majority of the configurations of this where this loop is anterior. And what happens is you pull back and you, you angle here and shorten this as small as possible. And then I do something called the preload. So before I start applying torque, I invert the head of the instrument at least once, hold the tension in the head. And then I slowly start letting the tension go through the scope and unwind at the same time. So I very rapidly put on 360 up to 720 of anticlockwise to, to resolve this. And if you don't do it quickly, you flip out, right. That's the technique. It's easier said than done. Um Thank you so much. We have got a couple of questions. Um, um I think uh we've got a question about the balloon. What is it? And can you explain, you mentioned a balloon when you were talking about caps and um calf. So this thing here is a balloon. It's on the Pentax IOP. And essentially what it does is it uh fixes all on at a so you insert to a certain point, blow up the balloon and allows you to strain the scope behind it. So that is one way of taking loops out. The other thing it does is if you block up the balloon, it stabilizes the tip if you're doing therapy, but it's uh it's only on the Pentax scope that you can get that and it's a, it's a specific scope. Thank you for that. And then there's a question about Entonox. Um, when do you use Entonox? Um, this, this, uh, colonoscopist finds that they normally fail, they have a higher failure rate with ox in difficult cases. So, and, and so firstly, if it's a really difficult case, they're probably gonna need sedation and if they've come on date and you've got a problem, uh, if I use, I use an in a proactive position, so let's say the patient's uncomfortable here and I can see this ly forming what I'd say to the nurse is, ok, let's give the patient an ox and they take five deep breaths before I do anything, get the intern loaded. So they're a bit away with it and say, take a deep breath in and another one and another one you get through the difficult part and then you take the inter knots off them. Ok. So it's a short, so I use it be, I anticipate, there's gonna be a problem and I preload them with the annex. But the reality of it is the interox is not as good as conventional opiates, right? So if you've got pain, you're gonna have to give them some fentaNYL cos it works. And the problem is you're all constricted by, you know, the current guidelines which, which are fine as a guide. Uh, 2004, there was a review and there's loads of patient related deaths from sedation. So they give you guidelines but they are guidelines and I, you know, if you come to watch me in my unit, I'll, I'll do an ESD and the sedation and the patient will have 200 of fentaNYL and you know, 30 mg of midazolam over the course of 2.5 hours because that's what they need, then don't die of respiratory arrest. It's in a controlled fashion. So if you have a particularly difficult patient and you have to give them more than you're normally giving, that's what you have to give. That's what we do on the ward. That's what you should do in, in the in the room. You obviously don't wanna flatten them right from the start. So if you titrate it, if the patient is gonna get a pain, you need to give them analgesics, you know, or they're not suitable and you need to reboot them for a port for this. But if you draw the line at 100 mg of fentaNYL and 5 mg of Dazla, you will fail in a significant proportion of patients because of pain because some people will just need more drugs than that. Um And you, you need to square that cos it it'll be an adverse event, but you, you will know what I'm saying is correct and some patients will simply require more analgesics than that. And you, you know, if you're using it every, every second or third patient, you've probably got a technical problem. If you're using it once every 50 or 100 patients, it's probably right. So I do use Entonox, but it's not the best I not to use it um for the cecum uh because it's medial, you need the patient in the right lateral and that's usually enough to get you into the cecal pole. And the weight of this pushes you into the cecal pole. And if you're still not getting down anticlockwise torque will bring the splenic fracture forward and it will effectively drive the scope in so suction, anticlockwise torque right later will get you into the cecal pole. Um If you're wondering about where the valve is and there's your appendix orifice here. Um There's something called the bone arrow sign. So there's your appendix orifice, you draw a ball and the arrow will tell you where the uh uh all cecal valve is. So this is the case, there's the appendix orifice here. So the valve is going to be across here at seven o'clock and of course, there it is. OK. So if you don't know where the valve is gonna be, that's where it's gonna be. You can use what we call the bone arrow sign and intubation of the A Ileocecal valve. Uh Katie asked me to touch on this. Um So you need to orientate yourself within the cecal pole, identify the fold and oriented the way I do it is I put it at nine o'clock, I push the instrument in, I slowly withdraw and tip in with anti clockwise talk. OK. Let me show you what I do. Doesn't a cat. Um I'm gonna see if your valve is. Uh So, so this was a tertiary referral. You can see there's a big polyp sitting in the cecal pole and they weren't sure whether it involved the appendix or not. So I've just checked the appendix. It doesn't involve that. Next thing is to check whether or not it involves the eye. Uh tria pole, obviously, you need to identify the appendix. Either structure of importance is probably the, obviously the valve. So with him in his right lateral, there's the valve on the left hand side uh between six and nine o'clock. So we're gonna advance the tip beyond the valve. Yeah. So push the tip beyond the valve and then we're gonna handle the left wheel in into the mucosa. So uh the cap's coming along closer and then you see the first lip of the valve coming interview and I'm pulling back here, which is there and we're gonna increase the angulation to the left hand side. So it's wheeled to the left and as it begins to slide, I'm gonna rotate anticlockwise and as you get in you just anticlockwise talk and as I say, it brings the spin forward and dries you in all Right. And then I usually add a bit of water not fully in. We are now I recorded this yesterday for you just, you said I need some ti intubation. I think it's something that surgeons don't do very often from, uh, you know, I used to really struggle with it so I don't know about you, but I'll ti intubate or at least give it a go one or two times on every patient. I agree. I'll give it a go. But I'd rather you spend time looking at a sequel and trying to get you better looking at, I think it's a skill worth having because you need to um uh occasionally you will need to get in. So it's worth practicing it a few times to have a technique. This is also from yesterday. This is another case. S thank you. Just freeze the screen. You'll see that the A val was at six o'clock here. Um And the first, the, the prominent lip running from 9 to 6 is the first fall. So ideally for intubation, you want to get beyond the first fall and then you want to angle the tip in the direction of the valve, right? And it's got a cap on. So it's gonna make it a little bit easier. Um And as we pull slowly back, that's the back lip and you can see the A signal, the all are coming into view at sort of nine o'clock. So I start to will tip, anti clock wise here and tip to the left, using the small wheel, you'll see, will naturally go into the ilium and then to help, you can have a little bit of fluid and we're in. Ok. So that anticlockwise rotation drives the tip forward. And if you've got the alignment correct, then you're going to enter into the A, I've seen a lot of people do what we call a pullback. So they'll get in in the six o'clock position, tip down and blame the pull back. But I would encourage you not to do that, look to see where the lips are and do everything in a dedicated fashion. So you can see that the anti rotation drives the tip forward, then we can add the left wheel, which does this. And if necessary, we can add a little bit of tip down. But as you're rotating in, if you add a little bit of air or fluid and pulling back slowly and rotating anti wires, you drop it. So why is that important? Well, uh you should have looked at Los Triangle, which is one of the blind spots of the colon, which is the area between the appendiceal orifice and the back of the A acetyl bile frequently missed. That was where the polyp was last time. And there's lots of other areas of blind spots of the colon. So when you're withdrawing and we're coming to the end here, um you need to optimize these areas. Um, retroversion of the rectum really important as well. Retroversion on the right side. If you can do it, we haven't got time to get on that today, but also a useful tool. Um So quick question on retroflexion at the beginning or the end because a lot of gastroenterologists say do it when you've got the good analgesia on board. I don't mind when you do it just don't forget to do it. So I agree with you. At the beginning, the analgesics is maximal. So you can retrovert the added advantage of doing it at the beginning is if there is a significant pathology at the inner rectum, let's say this is a cancer that might actually change how you manage the patient for the rest of the procedure. You could do a lot of, you could do a lot of pathology taking off here, find they've got a cancer at the rectum and then they present with a, a delayed perforation of the transverse colon. And uh Katie will say, well, that's not really the operation they need. I wish she'd left it alone, right? So it's probably worth monitoring where the pathology is before you start doing it. So therefore, doing the retroversion in the rectum at the beginning is probably logical for lots of reasons. Traditionally, it was always done at the end, but II would encourage you, but just to remember to do it is the key thing on withdrawal um you need the optimal position. So I go from right lateral to left lateral, left lateral, come into the transverse colon back around. Put the patients supine come back around in the supine position. That's what we call a double pass. Come back in the supine position to the splenic venture. Go back in. Put the patient on the right, come back again. That's what we call a double pass, right lateral, right lateral, I'll lose the view. I'll flip the patient onto the back and then back onto the left lateral into the rectum. That's what I do. These are the optimal patient positions for putting gas and distention in the colon. I would add to that. You should be using um BuSpar on everyone except those who've got a tachy arrhythmia or they've got some allergy to BuSpar. I would appeal to you to tell your nurses to stop asking about glaucoma. Cos Buscopan has no effect on glaucoma. It, it precipitates acute angle glaucoma, which is an ophthalmic emergency. And the only people who are gonna get that are the people who don't have glaucoma. Everyone who's got, it can't get acute. If they've got open angle, the bottom line is you don't need to worry about glaucoma. You need to give Busan and if they develop an acute painful red eye after the procedure, that's an ophthalmic emergency, that's what you need to know. Um And then you look carefully and just encourage lots of people to help you look otherwise you will miss stuff. So um we're just slightly over time. I apologize for that. But I would suggest that colonoscopy is a paradox in behaviors. The slower you go, the more quicker you're gonna get round pulling back is often the best solution in your toolbox, particularly when you're trying to move the tip forward, believe it or not, because you straighten everything and you gain control, keep this shaft straight by frequently pulling back and pleating the colon. And then you must understand that you need to be able to logically solve the problems proactively and be proactive and develop your conscious confidence, be mindful of when external pressure is likely to work. And also which is the optimal patient position. And I would encourage you to ask your trainers about being have training on your scope, tracking use of water pump, distal tip attachments, et cetera, et cetera. And if you want more of this, you, we got loads of stuff at gigs and I know some of you've got subscriptions already and there's some of it free. If you want to sign up, there's loads of stuff there. Um I'll have you stay on if you want to check any more questions. Um But I'm finished now. That was great. Thanks, Doctor Anderson. Um So we've just got one other question that I've not answered yet. That was about um ti intubation for drag certification cos it now says 60%. But it's a bit vague when I looked up. Is that 60% just for patients where you need to go into the ti, or is it 60% for all cases? Probably all cases? But honestly, Katie, I don't know. Yeah, I just looked it up and it, the wording is in patients with suspected IBD anemia, chronic diarrhea. So that seems to be those that require it to be done. Six out of 10. Not great. I would, I would do what two kids, which is misleading but um former Miss Cross, congratulations on your marriage. Um er I would encourage you to have a goal once or twice. I think that's fine if you can't get in and leave it and you'll just get better at the maneuver. So um great. Any other questions from uh the audience before we wrap things up? That's several people saying thank you very much. That was brilliant talk. No, thank thank you very much John. Absolutely brilliant and always a pleasure to hear you. So so wonderful. Um So if other people have questions, otherwise they can start the thread with the Dukes Club community and um thank you for organizing this Katie. Really brilliant. Yeah. No, just say a big thank you to you on behalf of the Dukes Club, we really appreciate you giving your time up. Um Yeah. No, it's brilliant talk um As as we expected. So, ok, thank you guys. Enjoy. Thanks for 11 end there. Thanks. Take care. Bye bye.