Complex Colon Polypectomy in the Community Setting
Originally Broadcast: July 12th, 7:30 PM EDT
Approaches for colon polypectomy intervention significantly vary from hospital, patient, lesion morphology, and the availability of tools to assist advanced endoscopists. As a GI professional working in the community setting, Dr. Patrick Saitta (Ascension St. Thomas Hospital Midtown, Nashville) discusses some of his experience and strategies with complex colon polypectomies.
Successful therapeutic endoscopy in a community setting
Interventional technology for complex polypectomy (demonstrated with case videos)
Case videos and real-world examples will complement instruction and recommendations around the topics listed.
Recommendations and answers to questions are reviewed in a Q&A session immediately following Dr. Saitta’s presentation.
Hi everyone. This is Tom Zarella with Lou Mendy. We thank you very much for joining us this evening for this live webcast on complex colon polyp ectomy in the community setting. Tonight's webcast is organized by Lou Mendy and Lou Mendis Vision. Friend of surgery includes multiple aims, producing risk and complication rates, enhancing patient recovery and increasing patient satisfaction. Blue Mindy's key product is diluted and and a Luminal interventional platform which is a disposable dual balloon endoscopic accessory that enhances endoscope functionality. Our speaker tonight is Dr Patrick Saida Dr Side is a gastroenterology physician with ascension Medical Group. He is board certified in gastroenterology and an assistant professor at the University of Tennessee Health Sciences Center. He's also the director of interventional endoscopy at Saint thomas Midtown Hospital in Nashville, Dr Sadeh, thank you so much for supporting his webcast tonight and please take it away because I just want to thank everybody again for joining us. Just a quick breakdown of my practice as we, you know, start to talk about trying to implement EMR into the community setting. So I work for a hospital based practice. Um We have eight guys who are basically covering three different hospitals. My particular hospital has four G. I. S that are stationed here. I'm the only interventional endoscopy ist here. We're roughly at 700 bed tertiary care hospital in downtown Nashville with five endoscopy rooms too. Flora Skopje interventional rooms. We're doing about 25 procedures per day and that's including bronchoscopy procedures as well. Um I go to one satellite office that is outside of Nashville and go to two separate endoscopy centers and just kind of giving you an idea of my procedure breakdown. I'm doing about 1100 hospital procedures a year. About 708 100 in the endo center. And you can kind of see the breakdown here. About 400 of us, 250 RSVPs for scheduling 1 to 2 E. M. R. S. A week and about two E. S. D. S. A month at this point. Ah Just also kind of looking at my breakdown in my daily schedule um and then just kind of making a comment that you know I am an assistant clinical professor with the University of Tennessee but we do not have a gi fellowship program. We do not have an advanced fellow. Um But we do supervise you know internal medicine residents on our G. I consult service here. So just some quick background. So again surgery for non malignant colorectal lesions remains common practice. So Approximately 25% of colon re sections are still happening for benign disease and that rate has actually been increasing Since 2000 suggesting possible changes in G. I. training practice trans. Just willingness to do EMR in general. But EMR is still Very effective. So it has a technical success rate about 95%. Um Where you know the knock on EMR is always the low en bloc resection rate which is less than 50% for polyps greater than two centimeters. But despite having a recurrence rate which varies anywhere from 2-18% up to 30% in certain studies, The reality is greater than 90% of these can eventually be managed endoscopic without requiring surgical management. In general risk factors that predict recurrence obviously larger polyp size Greater than four cm whenever you have to a PCC um areas that you were not able to respect. Uh and then intro procedural bleeding. The thought being that again that sometimes causes you to have to abort or change what you're doing or affects your ability to respect the whole polyp during the procedure. So generally, you know, most of our surgeons they are eager to get right hemi collect amis and they very much pitch pitch it as a very routine procedure that patients will do very well. But I'd just like to highlight that, you know, when patients go for resection for benign disease, it's not a completely benign operation. 30 day mortality approaches close to one morbidity Is up to 25%. With leaks and infection being most common, patients stay in the hospital even without complication 5-7 days. Um 4% are needing repeat surgery. close to 2% are eventually needing a colostomy and the health care costs are not insignificance. So you can see here even laproscopic collecting without complication, roughly, the health care cost is 18 to 55,000. If it's open collecting me and if you start talking about complications that cost can go up to 100,000 where it is when we compare this to E. M. R. You know essentially there's zero mortality if a patient stays in the hospital, if I do admit them, it's usually an overnight stay. You know again typically related to inter procedural bleeding that I thought I had to watch them. Um But again most of them are going home, They're typically recovering within a couple of days complication rates as you all are well aware. I mean for EMR I'm typically telling them roughly 1% risk of perforation, Bleeding risk can be anywhere from 5 to 10 and you know the cost here is much less about 5005 And a half, you know $5,500. EMR so as we start to talk about building this into our practice, building this into the community setting. So just kind of taking you through my process quickly. Um You know when I came on I was identifying, you know this was a unit that you know it was really doing a lot of bread and butter G. I. Um So we really had to build it from the ground up. We had to build it from scratch. So it's important when you're coming in identifying important capital and disposable equipment deficiencies in your unit. Um you really want to position yourself best you can before you start doing this, you want to make sure you have everything to be, you know, effective and delivering good care, high quality, you know, care when you start to do this because you don't want to start your practice say that you do this and then you don't have the right supplies and as a result of that you start to have complications early on. That will shut your program down before it ever starts. So you want to make sure your position for success, you have everything you need. Then you have to decide how you're going to market yourself, whether you use, you know, your online portfolio, whether that's using docks emit e linkedin instagram, whether you're using your practice or your hospital website to promote yourself and your skills. What I found is what's paramount is to educate your partners about what you can do. They will be typically extremely willing to pass their EMR cases onto you. So that's usually not a very hard sell. And as we then talk about other people to reach out to obviously other gastroenterologists, oncologists, surgical oncologists, colorectal surgeons, General surgeons in general. You know, I've gotten a lot of business from my practice. I have certain gis that you know refer basically all their E. M. R. S to me and what you learn is you don't really need a lot of EMR you don't really need a lot of G. I. S referring to you to build up a really robust EMR practice. Um I've also found that the colorectal is can be a really good source because again they will do colonoscopy but they once they learn that you offer this, I mean they're not usually willing to tackle big polyps and at the same time the ones here and I think in general in most places won't be rushing to do um re sections for benign disease. If they know they have somebody there to help them out with that, then it's important to train your staff. We, you know, have a binder that lists all of our supplies for every procedure so that everybody can refer to it, you know, and we make sure we have all of our supplies in the room ready to go for every case. That's very important. We don't wanna be scrambling in the middle of a case, especially if somebody is bleeding. Um you know, and then we we try to cross train all of our staff getting them all familiar with EMR because you never know who's gonna be out of town or who won't be available or who will be sick but we do have an EMR team. We have people that are more skilled and when they are around, we stick to our EMR team and I think that you know makes us very successful gives us the best chance for a good outcome. So I'll talk about this um you know, one of the barriers and one of the hardest things is trying to learn how to manage implementing in general advanced procedures but you know especially E. M. R. And procedures that take longer into your practice. Learning how to schedule. You know how many you can book a week how long you need to book them for and so forth because you want to remain productive. I mean most of us we have our bu targets were expected to perform equal to our partners so when we take on these bigger procedure there there's not a lot of you know leeway for us to just you know take all day doing these complex procedures were expected to kind of you know do an equal share of the work so you have to figure out that balance. And then it's very important that as people start to refer to your maintaining strong communication with them. Um I think anytime you do a procedure talking to your referring, letting them know about the procedure, how it went, giving some feedback you know that's always great and it gives you a chance to keep self promoting yourself. And if they're doing things like they're taking too many biopsies they're you know they keep sending you things where they've taken several pieces off of the polyp, they're injecting you know they're tattooing under the leisure and doing things that induce fibrosis it's just driving you nuts. You know that's your opportunity to kindly give them feedback. You know and which also is going to make it easier on you in the future, but also just, you know, making yourself very accessible to these, referring. The more they know you, the more they talk to you, the more they're gonna feel comfortable calling you, sending you patients and so forth. So when we talk about barriers to building this into your practice, again, A Big one is just figuring out the schedule. You know, these are hospital dependent procedures. They're potentially going to mess up your schedule if they don't go according to plan. And at the same time, you're trying to balance this when you have, you know, your day probably pretty set with clinic and your other outpatient procedure, other advanced procedures. Um inevitably there's going to be some procedure delays. There's going to be some clinic delays. You at times might have to cancel patients because you just never know what's going to happen. Um and you just have to be prepared for that. You know, the patients get upset. There's delays. You have to be willing to take that on. You have to be willing to accept that your surgical colleagues are not gonna be thrilled about you implementing this at first, either because you're taking business away from that and so they see their volumes decreasing. But that's just something that over time, you know, there's plenty of opportunities for you to send them different, you know, reception patients as well. And to as you build your advanced program in general to send them plenty of other work to balance things out as you might be taking some of their you know, colon resection business. So when you do this in the community setting, the other thing to be aware of is you don't have a lot of support for academic endeavors. Nobody's giving you a lot of extra time to do research. You typically don't have residents and fellows too help you with clinical trials or data collection or if you're wanting to do abstracts, you're very much going to be doing a lot of this independently and you're not gonna have a lot of support from your colleagues in general. You know, if you're trying to do research and demonstrate what you're doing, I mean your partners are going to be fine with that as long as you're doing your other work responsibilities. Um Other thing, you know, as you get more successful as you do more cases you're referring start to send you more difficult cases. So what we've learned is is we've promoted our program is we've had more success. We get harder and harder cases. We get cases where we find multiple polyps that were left behind. Um We get a lot of previously manipulated polyps, we get a lot of unfavorable locations around the valve via pendants, the lectures. Uh but that just kind of comes with the territory and then reimbursement is always you know a barrier here because the reality is RV us are not really changing. If you're on an RV you structure, you still get six RV US for an EMR as compared to 4.5 R. B. U. S for a polytech to me that you know, so 15 minute case versus a case that could take 45 minutes an hour, sometimes a couple of hours with very, you know, very little reimbursement to show for it. Um Now the positive is that hospital reimbursement has gone up for this procedure. Um Recent CSMS values from 2022. It has gone up close to $2500 that the hospital is getting paid which is better. But you still have to really think about your supplies and you know, be smart about it because if you're losing you know too much with your EMR program, you know, you you will hear about it for sure. So we're all familiar with Harris classification. I just want to quickly talk about this because um again, I think lesion selection is very important. Like I said early on you want to be successful, you want to set yourself up for success. So you want to make sure you're tackling appropriate lesions so you can hopefully show, you know, again good results. So I'd like to show this slide. It just shows different polyp morphology. So again, we're all very familiar with these paris to a lesions on the top left. This is a pairs to a granular lesion. So it kind of has a cobblestone appearance and I'd just like to point out that these lesions are generally Going to have very low risk of some new coastal invasion less than 1%. So these are always very favorable lesions. But as you look at the lesions on the right these are all non granular lesions. So they're typically they have a smooth surface to them. These always have higher risk of some U. Coastal invasion. And I'd just like to highlight as you look at as you look at the ones that are what we call these Nagy alor mixed lesions such as here and here. These always have higher risk of sub new coastal invasion. But especially when you talk about a Nagy alor mixed non granular lesion where the risk of cancer or deeply invasive cancer can be up to 14%. And then when we look at cecil lesions we generally think of these you know being ones that we would probably want to tackle. Um You know because they're more cecil they seem like they'll be easier to manage. But I like to point out that the cecil non granular polyp Actually has a 15% risk of invasive cancer. So that again when you see a Nagy alor mix or assess all people especially the non granular type. You probably want to stay away from those those are gonna be better suited for E. S. D. Or sending to surgery. Another thing I've learned from the cecil types in general something to think about is that these are the ones in my experience that really tend to bleed. So what we've had the most leading issues tends to be with with these lesions in general. Just something else to be aware of and just kind of pointing out here that any time you get a depressed lesion, whether it's a paris to a plus to see with a depressed center or in general, just a to see lesion which is depressed the risk of suddenly coastal invasion and those is 30%. Okay, so really again e. s. d. or surgery is what you need to do with those. You really shouldn't be tackling those. So again these are these Nagy alor mixed types that we talked about. Um this would be one of the cecil non granular types that could actually have a 15% risk of cancer. So you look at it, it looks cecil looks like something you could tackle but actually has a pretty significant cancer risk and maybe a higher bleeding risk. The ones on the bottom clearly have depressed centers. These are the ones that are going to have a high risk of some new coastal invasion that you want to stay away from. And I'm just gonna kinda quickly touch on this. So again we look at surface pit patterns as well and the main thing to point out whether you use the nice classification here or if you use the kudos pit pattern Really, you're you know, if you see these kind of this kind of type five or the nice Type three Where you lose your pit pattern, you get these kind of very amorphous irregular vessels that is also indicative of some new coastal invasion and you want to stay away from that. So, this is just examples of some different polyps that we've tackled. Just kind of giving you more examples of of morphology. So, this was one again where, you know, looking at this, this was technically a large cecil non granular polyps. So this kind of goes against what I was just telling you. Um But it had a favorable pit pattern, a type four pit pattern. So we did elect to respect it. So, this is post for section one thing I will tell you, we had a lot of bleeding issues with this um significant bleeding. This was one case in recent memory that I almost had to send a surgery for bleeding. So ultimately, it did not come back with any cancer. It was a curative resection, but again, something you probably wanna stay away from Now. This was a large seven centim seek a polyp. This was again, cecil morphology but has clearly a more granular pattern and again a favorable pit pattern. So, this is one that, you know, we should be able to tackle. And again, I'm just showing on the left a lot of times. I kind of do a hybrid underwater EMR technique. So this is me kind of putting the lesion underwater, showing a view there and on the rightist post resection. Again, this one did not have any cancer. It was a curative resection. So this is we talk about these laterally spreading non granular type tumors. Um So if we refer back to that morphology side, like I said, these have about a 4% risk of deeply invasive cancer. But again, that's acceptable. These are using ones we can we can tackle. Again, it had a favorable pit pattern. If you look at some of these pictures here, especially, you know, it might look a little depressed, but again, this was a top that had been previously manipulated. Um and you can also kind of appreciate if you look at this picture. This was one that was right on top of a tattoo. Um So a lot of things kind of going against us here, but I did not think that there was invasive cancer here. I guess you can also see the tattoo appeared. Um Well again we were able to respect it and again, there was no evidence of cancer and this was a curative, you know, reception as well. And like we talked about, we start to get more challenging cases, the more we, The more we do this. And so this was a six cm pile up surrounding the bicycle valve and as you can see here uh invaded into the yellow sickle vow. Um But again, favorable morphology. It was a to a granular, so like I said, really low risk of cancer, less than 1% favorable pit pattern type four. Um So again we were able to resect it successfully, curative resection, no cancer. This is just kind of showing you with the icy valve looks like after we respected it nice and clean. I did have to go quite a waves into the orifice to get this out. And this is the last one I'll show you. So again, this is a cecil granular type. It was very bulky lesion took up about 50% of the rectum but again favorable morphology, favorable pit pattern. So we're able to successfully respect it. We again have no evidence of cancer on the right, you know, with this big defect in the rectum, I sutured it and so we can see, you know, our closure after endoscopic suturing. So again, this is our di lumen device um that we are utilizing for these M. R. Procedures and I'm gonna talk a little bit now about, you know, the advantages of the the lumen device. So one thing that the lumen does is it gives us a therapeutic work zone that we can work inside of. So when we Put our four balloon out, we essentially create this therapeutic work zone where we can put the lesion into the therapeutic work zone and this really creates a very stable scope position, a very stable work environment. What this is doing is these balloons essentially or preventing leakage of air. So again, as you try to respect this lesion, you're not losing air. If you know you have a spastic colon, it's preventing colon spasm getting in the way of your reception. If you had a dirty colon, it's allowing you to, you know, potentially maintain a clean field of vision because it can keep a lot of school or effluent out if you like to do underwater EMR or hybrid sort of underwater EMR technique. This allows you to kind of easily fill up the zone in between the balloons to help with your visualization and to help with that technique. So, just you'll see our lesion here in just a second. So demonstrating here again, this is a sorry, the video is going slow, but this was one of these large kind of cecil granular polyps in the transverse colon. And I think you could appreciate that. It was again, right on top of a tattoo which was not working in our favor. So here we are advancing our poor balloon, you're just going to see us creating this therapeutic work zone here and creating stability to tackle this lesion. So here we are in the therapeutic work zone. Again, you can see this kind of bulky cecil granular lesion right next to a tattoo again, it had a favorable kudo type for pit pattern. Here we are injecting I typically am using your eyes for all of my lifting when I do EMR just again here we are lifting the lesion and you'll see it start to snare here. So I always and using typically hexagonal captivate er snares typically 13 millimeter 27 millimeter hexagonal snares. I also will sometimes use a 10 millimeter captivate er which I find works really well sometimes with vibe Roddick areas treat my margin. So again as we talked about cecil lesion and here we are encountering bleeding. So we're using our co ag grasshopper here to deal with the bleeding. We're tinting away from the sub mucosa and coagulating to get homeostasis. And here we are just respecting more pieces of the politics. Part of the reason I elected we're showing here some of the conduit function which is allowing us, this was such a big polyp. We had numerous polyp pieces that we're getting into our field and impairing our reception. So this allowed me to use the conduit function too quickly remove these parlor pieces, clear them from my field of view and continue working and this just shows you how quickly we can use this conduit function to remove the scope, remove pilot pieces And get back to our lesion really within 1-2 minutes. Um so that's just a really effective used for the device again here we are taking more pieces. Again, very bulky polyp came out in multiple pieces. This is really where the conduit function helped us to keep clearing these out of out of the way. We also dealt with quite a bit of bleeding and so bleeding, you know, kind of your scope land starts to get dirty. Um So again, this gives us the ability to pull the scope out quickly clean the lens and continue to see what we're doing. So again, just really demonstrating the conduit function and how quickly we can move in and out here. So, this is me using hot avulsion technique with hot biopsy forceps, there was some residual tissue in the center of the lesion and sometimes it's very hard to tell is this residual at an ominous tissue. Is that just vibe Roddick tissue? Obviously this was a real vibe Roddick lesion on top of a tattoo. And again, sometimes I'll try to use a captivate er 10 or I try to use um Again, the hot biopsy courtship choosing avulsion technique. Now, I really don't like to do this. But here again, this area in the center that it was just very hard to tell was that residual adenoma. What is that scar? I got to the point where I was just not able to really respect it any further. And so again, we talked about how a pc increases risk of recurrence. I always do send off, you know, kind of separate biopsies from that area to see if that was even an ominous tissue. Um But again, I had to do what I typically don't like to do. And I had to a pc some of that tissue which will unfortunately increase our recurrence risk. Um And then I may be seeing my margins here, which I don't always do but has been shown in studies to reduce the risk of recurrence. And here we are one more time using the conduit function going in with our endoscopic suturing device. So this is another advantage we can quickly use the Apollo suturing device to close our big defect um without having to figure out how to advance this to the transverse colon or the right colon using the therapeutic gastric scope. So, this will be kind of the last part of the video here. Just seeing us, you know, featuring and closing this lesion. And and again, part of the reason why I chose the dillaman here. I you know, just kind of looking at that how it was located on top of that tattoo. I had a feeling it was gonna take a while. I mean it was a very bulky lesion. Like I said, sometimes looking at those big cecil lesions, I'm concerned more about bleeding and again, potentially the need to be able to kind of clean my scope. I also know looking at that really bulky lesion and this is our closure um that, you know, I might be needing to remove several polyp pieces. Um and it also just was not the most stable location. So it also helps the scope stability. So again we showed a lot of the conduit function that the dye lumen device offers in that video, allowing us to quickly remove and reinsert our scope, helping to maintain clean field of vision. Um option of easy scope exchange whether we're needing to put the endoscopic suturing device in with a therapeutic gastro scope, whether you know, again we maybe started with an adult kaleidoscope. You you need better reach reflections that you want to change theatrical endoscope or another scope. It will allow the better retro flexion to help the lesion resection. And then like we show there just helping with quickly removing palla pieces with a big bulky lesion that start to get in your way. So I'm gonna show a couple more videos here is as we wrap up. So this was a to a granular lesion. Again surrounding the ilia sickle valve. Here again you can again see it's got Fableable Kudo Type four fit pattern. So just like that one I showed you pictures of earlier, you know, I think that this is a very favorable lesion to respect. But again, the challenge here is going to be location. Um So again here we are injecting again with your eyes. This is just kind of showing the lesion after we injected here. It's kind of hard to appreciate the icy bow, more of this here. So we start dissecting and I'm kind of working from the edges first, I'm not really starting around the iC valve orifice. I'm kind of working from the edges A lot of times. I'm not using a big snare here here, I'm using the captivate er 10 um Lucas, you can't really take out big pieces with a to a lesion around the icy bow. So I'm kind of taking what the lesion is offering me um And we're using kind of that small captivate er 10. Now here again, we start to accumulate a lot of pieces, they're getting in my way, they're affecting our field of view. So we can quickly put these into a Roth net and we can quickly get these pieces out of the way as we demonstrated with our last case. So again, just kind of quickly demonstrating how we can quickly come out and then get back into our lesion site um here we are quickly advancing back to the lesion site. So again, these icy valve polyps, I find the lumen very helpful here um you know, because again, this is an area where, you know, again it's going to take more time. It's important to maintain a very stable scope position um and I'm gonna show you another technique here in a second where the die lumen, you know, it's really beneficial I find with the icy bow, follow up. So here, you know, what's happening is I'm having more and more trouble identifying the icy vow or offices I'm respecting. So what I'm gonna do now is I'm gonna put a guide wire in so I'm leaving a guide liar in and I'm again gonna use the conduit function of the device to leave this guide wire in to help guide the rest of my reception. So this shows how you can kind of use the kind of it function, leave a wire and then we're going to quickly go back in alongside the wire and then that's going to guide the rest of our reception. And I find that this technique is very helpful as we start to, you know, kind of lose our orientation a bit as we're respecting these. I see about politics, you really want to, you know, maintain where the orifice is. So here we are, we have our wire in place, we're quickly getting back now we have the wire Again, I'm using my captivate er 10 basically. Now snare pieces out of the icy bow orifice and the wire is really helping to kind of maintain or orientation here. Kind of see how the captive eight or 10 just works really nicely kind of snare these pieces out of the icy bow or of this. So we just kind of keep working this technique here using our wire to guide us and this is probably our last piece here that were kind of respecting out of them under the icy valve so you can see us respect this piece here. So that piece is removed. We're starting to look nice and clean. It's looking more like ilium there. I'm not seeing any more of an ominous tissue. This is what it looks like post resection. Again, we're kind of coming out of the icy bow. I don't see any more residual adenoma. You saw a little tissue island there that I later went back with and just took out with the biopsy forceps again using hot avulsion. And here we are again using endoscopic surgery. So it's always a little bit tricky with the icy valve. Like how much of this are you going to close? Um Typically we're doing a partial closure here, looks like our video might be freezing on us. But um, typically we're doing a partial closure here. Um, but again, I'm kind of using this guide wire to guide me where the orifice is. So I don't close the orifice. Um, sometimes I will use clips here. I elected to use the suturing device. Um, so you'll see. We do close some of this, but ultimately, I leave some of the, some of the lesion, some of the defects exposed to make sure we maintain the patent patent of the icy vow. This is probably our last bike here. There we are again coming out of the icy bow. We've actually closed most of the lesion, but left some of the defect open. So again, kind of the last slide about the looming advantages. Um, just really helps with colon manipulation. So again, maintain stability. Um, we've all encountered issues where, you know, a lot of times people don't take out big polyps because of the location or because the physician was unstable. And so again, this allows you to maintain a nice stable position to work as long as you want to get the polyp out. Also, you've been in those situations where to get to a lesion. Um you know, again, your texts are having to apply a lot of abdominal pressure to keep you there and that's not really feasible for a long EMR procedure either with the lumen. It's rare that you're needing abdominal pressure at all. And, you know, in general, once you kind of get to your position and stabilize yourself, you're stable. Your texts aren't having to do anything, They appreciate that. Um so, you know, you can maintain this nice stable position. And sometimes when you have these lesions over a fold around, if lecture, using the balloons can actually straighten the colon out and kind of pull the lesion into view and give you better exposure. And also you can use this device when you have a difficult colon, you're not doing an EMR. But you get referred, you know, the patient that as incomplete colonoscopy, they've been told they can't, you know, they can't get a complete colonoscopy. There's too much looping. It's not possible. Um I used to actually use my double balloon scope for some of those but now I just you know, we use the dilemma device supports very effectively. So again, conclusions Approximately 25% of colon resection still being performed for benign disease. But as we talked about surgical morbidity and mortality with these, you know, collect amIS for benign disease are not insignificant. Okay, colon EMR is still a very technical, technically successful procedure when performed in expert hands. And you know, despite the risk of recurrent disease, you know, recurrent disease can usually be managed. Endoscopic li appropriate lesion assessment is paramount. You know, reserving those with favorable morphological new coastal pit and capillary patterns. Um you know, just making sure that you choose to tackle the right lesions and and that you also refer, you know, appropriate lesions for potentially SDI or surgery. Um you know, if they have a higher risk of deep southern coastal invasion, the lumen facilitates technical success and efficiency of EMR by providing yeah. Kalanick manipulation this therapeutic work zone and this conduit function that we've demonstrated nicely in these videos tonight. And it's got a very short learning curve to implementing it into your practice and then again just building this successful EMR practice in the community community setting. It's not always the popular option for your practice or for your hospital system and it requires a significant time commitment, you know, with unsatisfactory reimbursement. So you have to be willing to to take that on and make that sacrifice and that kind of concludes our lecture if we want to move on to questions Thank you Dr saida. Um we do have a few quick questions here. We have a time for maybe three or four. Um one question that we got was around the therapeutic zone that you mentioned earlier in your talk. How often do you typically use that for balloon to establish a a therapeutic zone? And if not if it's hard to estimate how often um what are the scenarios where you decide to go ahead and use that? Sure. So actually I I don't use that feature as much um that pile up that I tackled in the transverse colon that that I showed you. Um again that it sometimes just depends if I'm getting the appropriate whole instability that I need by just inflating the one over to, you know, balloon or not. I mean many times with EMR Not using the four balloon is fine and you don't need it. But sometimes if you're not getting the scope stability you want, it can offer that additional scope stability or like I said, sometimes depending on where the lesion is. Sometimes I'm having an issue with exposure. Again around Affleck shirt more more like with lecture situations, but um sometimes just kind of depending on how it lays over a fold. Sometimes that will, you know, also allow you to straighten things out and it can be useful there And then you know, again like I said sometimes you get in situations where again I don't intend to use it, but it's not the cleanest colon. Um So we're kind of getting school and a lot of fluid in our way. Um You know, and or again it's kind of a colon that's more spastic. It's not cooperating as well with us. And that's where you can really utilize that to try to eliminate some of those factors. And also if I you know sometimes again it helps with underwater EMR but a lot of times it's it's not necessary for that. I'll tend to, you know, put a lot of these polyps underwater. I think it just sometimes helps the polyp tissue to float. And that helps me too sometimes manipulate and grab some of the polyp tissue easier. I just implement that technique a lot. It's not imperative for that. But sometimes it helps with that too. Thank you for that. And actually you touched on the second question that I had which was around underwater EMR And when you typically elect to do that sort of similarly to that first question about therapeutic zone, when you elect to to kind of do an underwater EMR, you were just mentioning there's something about the lesion where you know, that might be an advantage if they'll call up actually I don't do I am not brave enough to do a straight up underwater EMR without lifting. So I that is not part of my practice doing the technique where it's purely underwater and I do not lift. Um I do kind of my own hybrid version where um again I lift as you saw but then I tend to put most of my lesions underwater. Uh And I just find that that really helps again to with getting some of this polyp tissue to cooperate better. Um I just find that it makes it sloppier it makes it easier to manipulate, it makes it easier to receptor. Um So I use it in almost all my cases. I will say that if you're dealing with a dirtier colon, you know, and you know that it's not gonna work very well you need a clean colon because it gets very cloudy and it it just it's a hindrance if you don't have a clean colon. So that that would be a situation where I I'd stay away from. But if it's clean and I can fill it up and have good clear irrigation. Um Then I I find it to be you know very helpful with most of my cases. Perfect. Thank you. So one another question came in and it's having have to do has to do with circumferential EMR and apologies in advance to the person who asked us if I don't get the question quite right. But they're asking for your thoughts about the possibility I think of an I. C valve stricture After doing a circumstantial EMR what are your thoughts about that or how you know what's your general um you know approach to that? Yeah so so I um you know if I'm when typically I haven't had issues so much when I when it goes around the rim of the valve but doesn't invade into it. So if we're not getting that actual invasion into the terminal ilium I typically have been able to respect it and I haven't had a lot of stricture issues and I haven't necessarily treated those with steroids. Um If I get more into the valve into the T. I. I will typically inject those with steroids. Um You know and again you know I'm starting to do more and more of these so it's it's hard to say. I mean I can tell you the ones that I'm the most concerned about again because it's growing into the valve. Um I'll inject those with steroids and the ones that I have you know done the follow up on so far I have not had any stricture issues on those. Um But again is that because of steroids or would it have not made a difference? Um But I don't think there's any form in you know anytime we're doing something circumferential two, inject some steroids after. I don't think there's any harm in doing that. I think it can only benefit us there potentially. Mhm. Got it. Okay thank you for that. I'm going to try to fit in one or two more questions here if that's alright with you? We did have a question come through around reimbursement. I think you alluded to this in your conclude conclusions where you mentioned that initially there's some unsatisfactory reimbursement scenarios and a time commitment. But when does that typically turn the corner or how did it turn the corner your facility in terms of navigating those reimbursement challenges or hurdles. Um How does it how does it how did that end up kind of smoothing itself out as you started to use the dillaman? Well I mean in general the reimbursement part does not in terms of obviously in terms of physician reimbursement, I mean that that doesn't change because I mean the R. B. It depends what, you know, but even if you're whether you're on R. B. U. Or not um you know, you're you're not getting fairly reimbursed so you have to accept the poor reimbursement. Um You know that's just that is an unfortunate reality here is that you know you take these cases on which sometimes can take two or 3 hours and it's always just you know hard to swallow but you you know that your partners and the other people you work with are in the same time knocking out multiple colonoscopies that are taking 15 minutes and basically getting paid the same and so it's a big, it's a big pill to swallow. But it is the reality, You have to have a passion for this. You have to want to do this. That part doesn't really settle itself out. Um You know, in terms of fortunately the hospital reimbursement has gotten better, but so now, I mean it can be more of a break even situation for the hospital, but they're not making any money on these and typically they're losing money. Um I do, you know, obviously, you know that one negative to the dilution is, you know, cost. I mean that's that's always gonna come up With this. I mean, you know, it's currently $1,500 unless that price has gone down and we're talking about hospital reimbursement of $2500. So you know, that's a big part of the reimbursement right there when you elect to use the device. But the device potentially, you know, is going to make you more efficient and able to do these procedures faster. Um But you know, that's kind of the balance. But in general, you're not making a lot of money on EMR I mean because all these supplies that we alluded to. I mean they are just the closure. I mean the reality is if you suit your or you use a bunch of clips to close your defect, which you are probably going to do because if you leave a big defect open, especially in the right colon, you're taking on a significant bleeding risk. Um You know, you're using a bunch of clips or suturing device. That's 1000 bucks right there just on your closure. Um, so this is kind of a break even or the hospital is losing. So you really just have to offset by proving your worth in other ways. I mean, you're offering the surgeon, you're offering the service. This is bringing a lot of, you know, referrals to your hospital, which some of these you're not gonna be able to remove. So some of these are gonna go to surgery. So the idea is just kind of in general, building up your therapy program, building, you know, an awareness about your hospital bringing in all these referrals. And so that's how it settles out. The hospital knows I bring in a ton of other volume and I bring in a lot of downstream revenue that I keep always, you know, reminding them of and that kind of all sets the losses we take with EMR, but it's not going to be a moneymaker for you. Yeah, thanks for that. As promised, I'm gonna fit in one last question. It's around referrals that you touched again on this in your presentation earlier on. The question is really around trends. Have you seen that the willingness to refer to you for these types of procedures has increased or changed in the last 2-3 years or has it been pretty much a steady state situation since you began your practice. You know, it, So the interesting thing is the number of referring physicians has not changed, I've been here Close to five years now. Um The number of referring positions has not really changed that much. Um But the number of referrals has has increased significantly. So I think it just speaks to you don't necessarily need a lot of referring. But what happens is when people figure out you're doing this more and more people around you G. I. S. The people in your practice, they're going to you know, start passing more and more of this onto you because at the end of the day it's very easy to kind of stick with the same practice Taking out small pilots during 15 minute colonoscopies for the basically the same reimbursement. Um So people are happy to pass this step onto you. So the number has not increased that much in terms of the number of referring, but the referrals have gone up significantly. Um And so like I said, I mean I'm always looking to market myself and get out there and find new referring. But even when it doesn't change dramatically, I I find that there's plenty of work and plenty of you know, reception work that keeps coming in. Well I'm sure after tonight's webcast you'll find that you've done a little bit more marketing of yourself and your practice and certainly expanding awareness about these types of procedures, so we're very, very grateful and I'm sure our audience members are as well. So just one more time, I just wanted to say, thank you. That's everything that we planned for Webcast this evening.