Gastroenterology & Endoscopy

In this in-depth episode, we dive headfirst into one of the most polarizing topics in modern gastrointestinal medicine - the heated debate between cold snare polypectomy (CSP) and hot snare polypectomy (HSP) techniques. Our host provides a comprehensive overview of these two pivotal polyp removal methods, exploring their pros, cons, and appropriate use cases. We learn about: • The fundamentals of CSP and HSP • European guideline recommendations for each technique based on polyp size • Comparative data on complete resection rates and complication profiles • Managing challenges like bleeding and tissue injury • The critical importance of polyp retrieval and histopathological analysis • Potential future advancements in endoscopic tools and techniques • Adhering to best practices and clinical guidelines Key Takeaways: - CSP shows a superior safety profile for diminutive (<5mm) and small (6-9mm) sessile polyps - HSP provides coagulation benefits for larger polyps (10-20mm) and bleeding control - Both methods demonstrate comparable resection completeness for 4-10mm polyps - HSP carries higher risks like delayed bleeding and deep thermal injury - Polyp retrieval quality is high with both techniques for accurate diagnosis - Technique choice depends on balancing polyp factors and patient needs - Ongoing research and new technologies will further refine polypectomy Whether you're a seasoned endoscopist or just getting started, this episode provides invaluable insights into optimizing polypectomy outcomes through the judicious application of CSP and HSP. Join us as we unpack this critical clinical debate. Links: Cold Snare vs Hot Snare: Polypectomy Factshttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC6506415/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10246601/https://www.gastroenterologyadvisor.com/colorectal-neoplasia/cold-vs-hot-snare-polypectomy-yields-more-favorable-outcomes-for-colorectal-polyps/ https://www.gastroendopod.com

The Couinaud classification is a vital tool in the field of hepatic surgery and diagnoses. It offers a comprehensive understanding of the functional anatomy of the liver by dividing it into eight independent segments. Unlike other classification systems, Couinaud classification focuses on the liver's functional aspects rather than its external appearance. Key Takeaways: Couinaud's innovative approach to liver segmentation has become a cornerstone in modern hepatic surgery, guiding surgeons in planning and executing procedures with utmost accuracy. By preserving the functional integrity of individual liver segments, surgical resection can be performed with optimal outcomes, enhancing patient recovery and long-term prognosis. https://www.gastroendopod.com

Episode Overview Key Steps in Resection Planning Resection Techniques Interventional Chromoendoscopy Resection Process Links: https://www.thepracticingendoscopist.com/p/endoscopic-resection-of-lst-in-ascending-colon [1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6353652/ [2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8984535/ [3] https://www.linkedin.com/posts/klaus-monkemuller_endoscopic-resection-of-lsts-precise-localization-activity-7159200748767989760-w1yU [4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7280838/ [5] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5308134/ [6] https://www.sciencedirect.com/science/article/pii/S2468448121002034 [7] https://twitter.com/EndoCollabcom/status/1753775490068832549 [8] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4414758/ [9] https://www.wjgnet.com/1948-5190/full/v14/i3/113.htm [10] https://www.elsevier.es/en-revista-ge-portuguese-journal-gastroenterology-347-articulo-large-colorectal-lesions-evaluation-management-S2341454516000107 [11] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8132716/ [12] https://www.mayoclinic.org/medical-professionals/digestive-diseases/news/reducing-post-polypectomy-bleeding-events-in-patients-who-require-antithrombotic-agents/mac-20479873 [13] https://www.giejournal.org/article/S0016-5107(20)34187-0/fulltext [14] https://dmr.amegroups.org/article/view/8102/html [15] https://www.researchgate.net/publication/260217120_Interventional_chromoendoscopy_Specific_aspects_for_the_colon [16] https://journals.lww.com/ajg/fulltext/2017/10001/risk_factors_for_delayed_colonic_post_polypectomy.527.aspx [17] https://www.sciencedirect.com/science/article/pii/S0016510720341870 [18] https://www.giejournal.org/article/S1096-2883(11)00003-9/fulltext [19] https://karger.com/ddi/article/37/5/364/95746/Accuracy-and-Pitfalls-in-the-Assessment-of-Early [20] https://www.dovepress.com/pathological-analysis-and-endoscopic-characteristics-of-colorectal-lat-peer-reviewed-fulltext-article-CMAR [21] https://journals.lww.com/ajg/fulltext/2020/10001/s3373_endoscopic_mucosal_resection_of_a_lateral.3371.aspx [22] https://www.linkedin.com/posts/endocollab_endoscopic-resection-of-lst-in-ascending-activity-7159541656394887168-cv5C [23] https://bmcgastroenterol.biomedcentral.com/articles/10.1186/1471-230X-10-135 [24] https://www.frontiersin.org/articles/10.3389/fmed.2021.728704/full [25] https://tcr.amegroups.org/article/view/48812/html https://www.gastroendopod.com

In this episode of the Gastroenterology and Endoscopy podcast, we explore the importance of understanding and mastering different types of polypectomy snares in the endoscopic field. Not all lesions are the same, and using just one type of snare for all scenarios is often ineffective. We discuss the advantages of snares with expansial memory and hexagonal or oval snares with double buckles. The range of polypectomy snares available is vast, and each endoscopist will discover the snare that best suits their needs through practice and personal preference. Factors to consider when selecting a snare include the lesion's size and shape, the snare's ability to retain its shape and durability, and personal comfort and proficiency. Understanding and experimenting with various polypectomy snares enhances the ability to adapt to different clinical situations and leads to improved patient care. Understanding Polypectomy Snares: A Guide for Endoscopists Polypectomy snares are critical tools in the armamentarium of an endoscopist, and it’s essential to become adept with at least two types due to the variability in lesion sizes and shapes. A single snare type cannot accommodate all scenarios. Here’s a closer look at the diversity of snares and their functionalities: Expansile Memory Snares:Hexagonal or Oval Snares with Double Buckles:However, it’s crucial to remember — there’s a plethora of tools available. Each endoscopist will, through experience and preference, determine which snare aligns best with their practice. Let’s delve into some of the key factors to consider: Lesion Size and Shape:Snare Memory and Durability:Personal Comfort and Skill:In summary, while the variety of polypectomy snares may seem daunting, understanding their unique features and testing different types can greatly enhance an endoscopist’s proficiency and adaptability in managing diverse lesions. Timestamps Keywords Gastroenterology, Endoscopy, polypectomy snares, tools, techniques endocollab.com newsletter.endocollab.com/subscribe https://www.gastroendopod.com

In this episode, we delve into the intriguing world of Cameron lesions, a medical condition first identified in 1986. We explore what these lesions are, their causes, how they are diagnosed, and treatment options. This episode is a deep dive into the intricacies of medical diagnostics and highlights the importance of detailed observation in the field of gastroenterology. Key Points Discussed: Introduction to Cameron Lesions:Historical Background:Causes of Cameron Lesions:Prevalence and Diagnosis:Challenges in Diagnosis:Treatment Options:Conclusion:Recommended Resources: https://endocollab.com/blogs/gi-endoscopy-tips-tricks/cameron-lesionshttps://www.thepracticingendoscopist.com/p/cameron-lesions Timestamps: - 00:00 Introduction to Cameron Lesions - 00:12 Definition and Association with Hiatal Hernia - 00:29 Discovery and Prevalence - 01:09 Causes of Cameron Lesions - 02:01 Diagnosis and Challenges - 02:37 Treatment and Management - 02:55 Association with Iron Deficiency Anemia and GERD - 03:05 Significance and Importance of Cameron Lesions - 03:26 Conclusion Keywords: Cameron lesions, hiatal hernia, gastric mucosal folds, mechanical trauma, local ischemia, mucosal stress, ulceration, EGD, proton pump inhibitors, iron deficiency anemia, GERD, size, overlooked, high index of suspicion https://www.gastroendopod.com

In this episode of the Gastroenterology and Endoscopy Podcast, we explore the world of water-assisted colonoscopy (WAC). WAC is a technique that uses water instead of air or gas during the insertion phase of a colonoscopy, offering numerous benefits for both endoscopists and patients. By utilizing water's natural properties, WAC can reduce pain and discomfort, straighten out the colon, and enhance visibility of the mucosal surface. This technique not only improves patient comfort but also plays a crucial role in colorectal cancer prevention by improving adenoma detection rates. Join us as we delve into the advantages of WAC over traditional methods and its potential impact in the field of gastroenterology. Quotes Resources Water Assisted-Colonoscopy (WAC or Hydrocolonoscopy)Do You Use CO2 and Water Immersion in Diagnostic Colonoscopies on a Daily Basis?Keywords water-assisted colonoscopy, WAC, hydrocolonoscopy, benefits, endoscopists, patients, concept, application, water, air, gas, insertion phase, colonoscopy, pain, challenging cases, colonoscope, bends, loops, straightening, angulations, gravitational effect, colonic elongation, loop formation, discomfort, sedation, water irrigation, visibility, mucosal surface, adenomas, precancerous growths, ADR, colorectal cancer prevention, air insufflation, water immersion, water exchange, duration, modified version, partial WAC, CO2, combination, tight angulations, colon elongation, cleaning, lumen, folds, polyp detection, modern colonoscopes, water jets, hybrid technique, suction, liberal use, overall quality, water, cleaning, mucosal surface, colonoscopy, debris https://www.gastroendopod.com

In this episode of the Gastroenterology and Endoscopy podcast, we discuss a challenging case involving a pedunculated duodenal adenoma. These types of polyps present unique challenges for endoscopists, requiring meticulous planning for a successful procedure. The goal is to achieve a complete R0 resection, removing the entire lesion without leaving any microscopic remnants. We explore strategies to prevent migration of the polyp into the bowel, such as positioning the patient in a decubitus supine position or using an antimotility agent. The endoscopist and assistant must be on high alert to catch the polyp with the snare, and having a Roth's net on standby is recommended. Chapters: [00:02:16] Preventing complications. [00:04:10] Preparation is key. Resources: Endoscopic Resection of Complex Duodenal PolypsDuodenal Polyp Resources on EndoCollab Quotes: Topics Discussed: Introduction to Pedunculated Duodenal AdenomaAchieving Complete Resection (R0)Preventing Polyp MigrationComplication PreventionTools and TechniquesManaging Immediate and Delayed BleedingProximity to the Papilla of VaterPost-procedure CareFinal Thoughts and GoodbyeKeywords: Gastroenterology, Endoscopy, pedunculated duodenal adenoma, endoscopic procedures, complications,closing the wound, post-resection, clips, duodenal endoscopic resections, bleeding complications, hemostatic hydrogels, Puristat, anticoagulation, proton pump inhibitors, healing process, polyp's proximity, papilla of vater, ampullary lesion, resection, side-viewing endoscope, complete R0 resection, pedunculated duodenal adenomas, preparation, plan, outcome, patient, insightful, helpful, practice https://www.gastroendopod.com

In this episode, we discuss the importance of improving colonoscopy prep and achieving better Boston bowel preparation scores. Colon cancer is the second leading cause of cancer death in the US, but it is preventable through colonoscopies. However, the success of a colonoscopy relies heavily on proper bowel preparation. Inadequate prep can decrease polyp detection rates by 27%. Patients are advised to follow a special diet and take a bowel cleansing solution prior to the procedure to ensure a clear view of the colon. The cleanliness of the colon is graded using the Boston Bowel Preparation Scale, with a minimum score of 6 recommended for optimal polyp detection. Unfortunately, the endoscopy center discussed in the episode noticed alarmingly low Boston prep scores among their patients. Quotes: Chapters: [00:01:45] Importance of Boston bowel preparation. [00:04:25] Thorough colonoscopy PrEP is indispensable. Read more: Improving Colonoscopy Prep and Achieving Better Boston Bowel Preparation ScoresCan I have your experience with colonoscopy prep? I have noticed that most of the patients we receive don't have a good Boston score? Keywords: colonoscopy prep, Boston bowel preparation scores, colon cancer, colonoscopies, bowel preparation, nurses, split-dose bowel preparation regimen, PrEP solution https://www.gastroendopod.com

In this episode we discuss using natural color changes called "biologic chromoendoscopy" to detect challenging flat colorectal lesions. Key Topics Discussed: - While sessile and pedunculated polyps are easy to spot endoscopically, flat and serrated lesions are challenging - AI, virtual chromoendoscopy, and dyes aren't reliable for flat lesions obscured by mucus/debris - Mucus changes light penetration, traps stool, and creates a hazy appearance - Two mucin secretion changes: lost O-acetyl groups and increased sialylation - "Chicken skin mucosa" refers to white spots from lipid-laden macrophages linked to adenomas, cancer, and juvenile polyps - Melanosis coli is dark pigmentation from lipofuscin deposits due to chronic laxative use - Recognizing subtle color changes is critical for finding precancerous flat lesions - Human eye notices what AI systems miss when looking for discolored tissue Key Quotes: - "I call the lesions' natural color changes 'biologic chromoendoscopy.'" - "Other examples are 'chicken skin mucosa' and melanosis coli." - "Recognizing these subtle color changes is critical for finding precancerous flat lesions." Links: Biologic Chromoendoscopy – The Eye Beats Artificial Intelligence References Made: - Mucin secretion changes in serrated lesions - Melanosis coli and anthraquinone laxative use - Chicken skin mucosa first described in Japan Keywords: - colorectal cancer screening - colonoscopy - endoscopy - polyp detection - flat lesions - sessile serrated lesions - biologic chromoendoscopy - natural chromoendoscopy - chicken skin mucosa - melanosis coli - mucin secretion - AI in endoscopy - virtual chromoendoscopy - chromoendoscopy techniques - lipofuscin - precancerous polyps - colorectal polyps - anthraquinone laxatives - visual characterization of lesions - hazy lesions - discolored lesions https://www.gastroendopod.com

Episode Overview: In this episode, host Dr. Alan Smith discusses a new hybrid endoscopic technique that combines aspects of ESD and EMR to improve resection of difficult to remove gastrointestinal lesions. Key Topics Covered: - Limitations of traditional endoscopic resection techniques like ESD and EMR - Overview of the ESD-EMR hybrid technique (also called pre-cutting EMR) - Step-by-step explanation of how the hybrid technique works - Types of challenging GI lesions the hybrid technique is useful for - Benefits of the ESD-EMR approach over standard resection methods - Limitations and alternatives to the hybrid technique Episode Highlights: - Laterally spreading colorectal lesions often cannot be fully resected with standard EMR snares due to slippery mucosa, leading to recurrence. The ESD-EMR hybrid technique creates a pre-cut groove around the lesion that enables complete en bloc snare resection. - Serrated polyps in the colorectum frequently evade polypectomy snares because of their subtle mucosal surfaces. The hybrid technique overcomes this with circumferential pre-cutting to allow complete snare capture. - For difficult to resect subepithelial tumors like lipomas, the combined ESD-EMR approach facilitates resection of larger lesions compared to standard EMR. - The hybrid technique decreases recurrence rates and lowers perforation risks versus ESD in less experienced hands. Notable Quotes: "But ESD and EMR have limitations resecting certain flat, slippery lesions. Laterally spreading colorectal polyps often slip out of EMR snares, causing incomplete removal and recurrence." "Making a customized groove around the lesion enables complete snare capture and resection of even challenging flat lesions." "While limitations exist, this innovative ESD-EMR hybrid strategy expands the range of lesions treatable by endoscopic resection while minimizing recurrence and perforation risks." Sources: https://endocollab.com/blogs/news/the-esd-emr-hybrid-technique-for-improved-endoscopic-resectionhttps://www.thepracticingendoscopist.com/p/the-esd-emr-hybrid-or-pre-cuttingTopics mentioned: Endoscopy, ESD, EMR, endoscopic resection, endoscopic submucosal dissection, endoscopic mucosal resection, hybrid technique, pre-cutting, GI tumors, GI lesions, laterally spreading tumors, colorectal polyps, serrated polyps, adenomas, subepithelial tumors, lipomas, en bloc resection, snare resection, electrosurgery, submucosal injection, submucosal dissection, polypectomy, recurrence prevention, non-lifting lesions, fibrotic tumors, gastroenterology https://www.gastroendopod.com

In the latest episode of the Gastroenterology & Endoscopy Podcast we explore the innovative realm of Hemoclips, or Through-The-Scope-Clips, and their pivotal role in enhancing endoscopic procedures. Initially designed for hemostasis, these multifaceted tools have now widened their scope, proving to be indispensable in a variety of clinical scenarios. Hemoclips Hemoclips, now often referred to as "clips", have seen their application extend beyond their original purpose of hemostasis. They are now employed for a range of uses including closing perforations, post-resection defects, marking, and attaching devices like stents and feeding tubes. For instance, during procedures involving gastric, esophageal, or colon perforation, clips can effectively seal the defect, averting further complications. This adaptation of clips over time truly signifies a leap in medical innovation. Understanding the Anatomy and Deployment of Clips: Grasping the anatomy and the mechanisms governing the deployment of clips is essential for their effective utilization. A typical clip comprises a stem with two arms with distal teeth. The design might vary; for instance, the arms' shape and number could differ, and so can the length of the stem. This length variation affects their use in narrow areas like small bowel strictures or esophageal stenosis. For example, a longer stem in a small bowel stricture could exacerbate the condition by rubbing against the mucosa on the opposite side. It’s imperative that we understand the anatomy to ensure the appropriate selection and use of these clips. Advancing and Applying Clips with Precision: The advancement and application of these Through-The-Scope clips demand precision and care. When initially advancing the clip into the working channel of the scope, it's crucial to hold close to the tip to prevent bending the arm. Once the clip has navigated through the working channel and reaches the tip of the scope, it should be gently pushed out, opened, and pulled back towards the scope. For example, when addressing a bleeding lesion, the clip should be open and advanced towards the lesion by moving the endoscope. And at that pivotal moment, when the clip is near the target vessel or defect to be closed, it should be pushed out with the hand, then closed and released by the assistant. This meticulous handling and application of clips can significantly bolster patient outcomes. Mastering the Use of Clips: The art of mastering the use of clips lies in a thorough understanding of their anatomy, their mechanics, and the knack of deploying them accurately, and applying them with precision. It's a journey of practice and learning that unveils the full potential of these versatile tools, thereby elevating patient care to new heights. Links / References: EndoCollab.com: A Visual Guide to Hemoclips ApplicationsConclusion: The Gastroenterology & Endoscopy field continually evolves with advancements like Hemoclips, pushing the boundaries and offering new horizons for better patient care. Mastering the use of these clips is not just about enhancing procedural efficiency but also about ensuring safer and improved patient outcomes. https://www.gastroendopod.com

In this highly informative podcast, we explore the world of Inflammatory Fibroid Polyps or Vanek Tumors of the GI Tract. We discuss everything from their manifestation as submucosal lesions to their immunohistochemical characteristics. Get valuable insights into diagnosis techniques, anatomical locations, and treatment protocols. You'll also learn about the importance of immunohistochemistry in distinguishing between IFPs and other Gastrointestinal stromal tumors (GIST). Join us in our deep dive into this intricate world of gastroenterology. Read more: https://www.thepracticingendoscopist.com/p/inflammatory-fibroid-polyps-ifp-or https://www.gastroendopod.com

A phrygian cap gallbladder is a congenital anomaly of the gallbladder with an incidence of 4%. It can simulate a mass in the liver during hepatobiliary imaging and is sometimes mistaken for pathology. A Phrygian cap, however, has no pathological significance and normally causes no symptoms. Links: What is a Phrygian (Cap) Gallbladder? https://www.gastroendopod.com

Ever wondered about the precision of medical instruments, how they are measured, or who pioneered this system? Join us on a captivating journey as we unearth the intriguing world of medical instrument measurements. We'll highlight the life and contributions of Swiss-French artisan, Joseph Frederick Benoit Chariere, the brain behind the French or Chariere gauge system. Used widely in endoscopy units worldwide, Chariere's precision instrument designs changed medical science forever. We'll discuss everything from scissors to syringes, anesthesia systems, and his innovative gauge system known for its uniform increments. As we navigate the practical application of the French scale, you'll experience how it aids medical professionals in delivering precise treatments. Our discussion breaks down the complexities of this fascinating system and reveals its role in delivering vital medical equipment like catheters and stents. To bring it all to life, we'll delve into an exciting case study of balloon-assisted endoscopic retrograde colongeopancreatography, illuminating the importance of these measurements in real-world applications. Stay tuned for this engaging exploration into the precision and innovation that is at the heart of medical science. Links: - https://www.thieme-connect.com/products/ejournals/pdf/10.1055/s-0043-119686.pdf - https://www.thepracticingendoscopist.com/p/where-does-the-measurement-fr-french https://www.gastroendopod.com

00:00 Intro 00:01:43 Spindle cell proliferation evaluation with Gave syndrome 00:03:07 Visit endocollab.com for more tips Gastric antral vascular ectasia (GAVE) or watermelon stomach is an uncommon but important cause of gastrointestinal bleeding and anemia, first described in 1953 by Rider et al (1). GAVE is characterized by a “characteristic” endoscopic pattern, mainly represented by red spots either organized in stripes radially departing from pylorus (“watermelon stomach”, or arranged in a diffused-way or “honeycomb stomach”). In addition, there is a nodular variety, where there are multiple enlarged and nodular folds in the antrum (2, 3). Despite this GAVE is often misclassified or mis-diagnosed. https://www.gastroendopod.com

- Importance of having a range of endoscopic tools - Different types of tools (snares, basket nets, caps, over tubes, etc.) - Choosing the right tool - Teeth for firm grip on foreign bodies - Dealing with capsule endoscopes in the GI tract - 1% getting stuck in the small bowel - Double balloon enteroscopy for removal - Visualizing strictures and ulcers via fluoroscopy - Preferred retrieval method: Rothnet or plain snares - Extraction of gastric bands that migrate into the stomach - Discomfort caused by migrated bands - Use of gastric band cutters or biliary wire and lethal triptor device - Requires patience and persistence - Challenges of migrated stents in the esophagus - Dilation of strictures can help - Pushing the stent into the stomach with an overt tube and cap - Grabbing the stent by its string and being gentle to avoid damage - Increase in tight strictures in the esophagus possibly caused by ingestion of pills - Standard practice to inject contrast after dilation for safety - Reducing risks of perforation or damage - Mastering foreign body extraction in GI endoscopy - Importance of equipping oneself with a diver https://www.gastroendopod.com

- Introduction to the management of colon polyps with thick and long stalks - Description of pedunculated polyps, specifically Paris zero ippy type with substantial stalk - Increased risk of bleeding during or post removal due to arteries in the stalk - Interventions to prevent postpolipectomy bleeding - Mention of clipping injection and endoloop techniques - Possibility of using a combination of these techniques - Explanation of endoloops and their operational difference from snares - Visual comparison between endoloops and snares - Endoloops lack the ease of opening and closing like snares - Standard procedure for endoloop placement - Passing a catheter equipped with the endaloop above the polyp head - Incremental reveal of the loop while guiding it to encircle the polyp head - Goal of snugly wrapping the endoloop around the polyp stalk - Positioning the loop about ten from the base of the stalk - Tightening the loop using the pushing ring or band - Color transformation of the polyp head and commencement of resection - Polyp head changes to a blue or purplish hue - Three stages of polyp removal: firm clenching, coagulation current, and cutting current - Caution regarding the use of clips - Need for vigilance to avoid complications with clips https://www.gastroendopod.com

In this episode, we explore a fascinating medical case of Mid-GI bleeding caused by an uncommon tumor: Cavernous Lymphangiomas. Dive deep with us into the intricacies of its discovery, diagnosis, and treatment. Episode Highlights: IntroductionDiscoveryIdentificationCavernous LymphangiomasClinical ManifestationsTreatment OptionsAlternative TreatmentsClosing ThoughtsKey Takeaways: Relevant Links & Resources: Detailed article on Cavernous LymphangiomasOverview of double balloon enteroscopy procedure.Guide on the various treatment options for gastrointestinal tumors.Next Episode Teaser: Join us in the next episode as we delve into another intriguing medical mystery that stumped experts. Don't miss it! Remember to rate, review, and subscribe to "Gastroenterology and Endoscopy" for more in-depth looks into unique medical cases. https://www.gastroendopod.com