00:00:00: Hello, everyone.

00:00:01: My name is Aigli and I'm the host of UG Podcast, educational and hopefully fun dive into GI world and beyond.

00:00:09: And today's episode is a little different from what we are used to.

00:00:12: Instead of a classic interview, you'll be listening to a roundtable discussion recorded in twenty twenty five as part of UG online course on the impact of polyp detection and colonoscopy.

00:00:23: It captures on an infiltrator exchange between experts on real-world dilemmas surrounding quality metrics, pathology, serrated lesions, surveillance strategies and artificial intelligence.

00:00:36: I strongly recommend watching the full online course after listening to this episode.

00:00:40: It's available on GutFlix via the link in the shoe notes and it's completely free.

00:00:46: It features practical tips on improving your ADR, scoping techniques, optical diagnosis,

00:00:52: AI

00:00:52: use, surveillance intervals, case discussions, and so much more.

00:00:57: Now let's get started and let the experts introduce themselves.

00:01:01: So welcome to the roundtable discussions.

00:01:03: My name is Raph Bischups.

00:01:05: I'm a gastroenterologist and I have a special interest in advanced imaging and therapeutic interventions.

00:01:11: I work at the University Hospitals in Lever in Belgium.

00:01:14: My name is Manuel Furnery.

00:01:16: I'm associate professor in gastroenterology at the University of Gena and part of the UAG education team.

00:01:22: I'm Veronique van der Voort and I'm a gastroenterologist and advanced endoscopist at the University Hospital in Limoges in France.

00:01:28: And I am Peter Sinonkel.

00:01:30: I'm a senior clinical fellow in University Hospital Leuven training in gastroenterology and endoscopy.

00:01:36: So after all the lectures we're going to discuss some well some hot issues and some hot topics that I think most of us are confronted with in daily life.

00:01:44: So the first thing I want to touch upon is actually the histology as golden standard.

00:01:49: Right?

00:01:50: So the pathologist is king or queen in our decision making.

00:01:55: We depend on what they write in their reports.

00:01:58: But I must say that often we are confronted with some contradiction.

00:02:01: So it happened more than once to me that I'm absolutely sure I saw a polyp and resected it.

00:02:07: And the pathology comes back as no polyp found.

00:02:10: That's one thing.

00:02:12: And then when you apply the optical diagnosis and you clearly see the nice type two pit pattern, it comes back as a hyperplastic polyp, while you are absolutely sure it's an adenoma.

00:02:23: And you can go into discussion.

00:02:25: And the third thing, maybe, is this serrated, which is an important polyp to find.

00:02:31: And it may very well be that you find a ten millimeter polyp in the right colon, and then you see, well, it has all the features of the wasp classification.

00:02:40: that says to me as an endoscopy, this is most likely serrate lesion and it comes back as I have a plastic polyps.

00:02:47: I think these are three scenarios that we encounter quite often in our daily practice.

00:02:54: So my first question to you, Manuel, with regard to the serrate lesion, the last example, how should we deal with that?

00:03:00: I mean, if you're absolutely sure it's an endoscopy, it's a right-sided, ten-millimeter lesion, because we learned from Peter that it's a different interval for that patient.

00:03:08: That would be like a three-year interval instead of a ten-year interval.

00:03:12: But then it comes back as a hyperplastic polyp, and all of a sudden, it's ten years again.

00:03:17: So what should we do with that?

00:03:18: Yeah, actually, it happens to me a couple of times that I was also collecting the pictures and say, oh, I can finally show a nice, a size-serrated lesion.

00:03:26: But at the end, when I saw the reports, they obviously hyperplastic, so maybe I'm not so good at optical diagnosis, or I cannot show this video case because actually it's not as a size-serrated.

00:03:36: But probably we must think about... either probably into, let's say, acceptance that the new diagnosis for serrated lesions are, that is enough to just see or found a... certain disrupted serrated creep into the specimen.

00:03:56: And another thing aspect is that we might have this distortion also just in the very buzzer layer of the specimen and not in all the through all the thickness of the specimen.

00:04:08: And therefore sometimes there's a superficial cut of the specimen.

00:04:14: these specimens sometimes arrive to the pathologies that actually are quite distorted or very small and they might be therefore triggered by technical issues.

00:04:27: And

00:04:27: this comes again to your questions like should we then rely more on our diagnosis or we still stick to the astrology report.

00:04:37: So but then Virini, how can it be that we see the polyp?

00:04:41: Let's say the tiny polyp that you taught us to take off now with cold snare.

00:04:46: But then the pathologist said, I can't find anything.

00:04:48: So how do you explain that?

00:04:51: Exactly.

00:04:51: It's a good question.

00:04:52: And I think it happened to a lot of us in clinical practice.

00:04:56: And as I showed in the video, performing a nice cold snare pull effect to me, it includes removing the polyp in the middle with a nice rim of normal mucosa around the polyp.

00:05:08: And the pathologist, he cuts the specimen that he receives.

00:05:12: And it's possible that if the lesion is so small that he only cuts the normal.

00:05:15: mucosa and so the report will say it's just a normal mucosa.

00:05:19: we didn't find a polyp.

00:05:20: So I think there is some room to really rely on your optical diagnosis.

00:05:24: if you're really sure you can go back to pictures or you can.

00:05:27: so I think we we should still keep on relying on our own optical diagnosis if we do it correctly.

00:05:33: OK, but that's a bit controversial.

00:05:34: So Peter, you explained to us the intervals for screening and when to do the next colonoscopy after screening colonoscopy.

00:05:42: And let's say that is just polyp number five, so to speak, to really make it a dilemma.

00:05:47: So what should we do with that?

00:05:48: Should we trust our own eyes and say, I saw that adenoma.

00:05:53: I did a nice classification.

00:05:55: And I'm like, let's say.

00:05:57: Like we say, eighty percent sure it is like that.

00:06:00: So what should we do with that?

00:06:02: Well, that's actually, again, a good question.

00:06:04: And I believe that it's a dual answer in the fact that we know that there is a mismatch between optical diagnosis and histology.

00:06:12: We know that in the literature it's been written up to fifteen percent.

00:06:17: And what Manuela said was very important.

00:06:20: You should focus document.

00:06:22: because you can go back to the polyp and see, okay, maybe I was wrong, maybe I was right, and I still think there's a polyp.

00:06:29: So if you don't have any photo documentation, you can't go back, so there is no discussion anymore.

00:06:34: And if you're still very convinced, there is a fifth adenoma, and the pathologist says, well, it's not.

00:06:42: I think you have to look for yourself.

00:06:44: How well am I trained in optical diagnosis?

00:06:46: But if you're very convinced, I should discuss it with the patient and say, well, it's a bit conflicting here.

00:06:52: But in my opinion, I would always apply the most stringent surveillance interval then and say, well, we'll rescope you after three years as the guidelines prescribe.

00:07:02: If it's OK, you can go back to screening interval.

00:07:05: I think there is quite a little harm in rescoping patients after three years.

00:07:11: Whereas Taking them in an interval of ten years, there might be more risk of a post-colonoscopy colorectal cancer, although the absolute risk for these PCCRCs is very little.

00:07:22: But you should be the one patient not being discussed with having a post-colonoscopy colorectal cancer, then you might get in trouble.

00:07:31: Yeah, but now you put yourself in a very specific place because I'm going to challenge you.

00:07:36: We heard from Manuele that we should use the endocoff.

00:07:39: We should use virtual chromatoscopy to improve our detection skills.

00:07:44: You showed us data on artificial intelligence or ADR or skyrocketing or number of polyps where colonoscopy goes up.

00:07:52: So we are confronted with another paradox, which is we do our utmost best to detect every single polyp.

00:07:58: But paradoxically, if we look at the guideline that you showed, it's going to be very easy to reach that five-polar bar, right?

00:08:08: So although we do a better job and take everything out, we're going to see those patients more often back.

00:08:14: So do you think we need to change these guidelines in the future, depending on how the endoscopy was done, on how the quality was assessed, and are we good enough to assess these ourselves?

00:08:24: What do you think about that?

00:08:26: Well, I think that's a difficult question, first.

00:08:31: In my belief, again, it all comes down to documentation.

00:08:34: Before you can discuss this, we really need to document what we're done, because high quality endoscopy, I can just write down in my report, I did a high quality endoscopy, but you should report it.

00:08:44: You should document the fact that you intubated the shekem, that you have a good bowel preparation in the patient, and that you did any... thing to optimize your optical diagnosis using, for instance, virtual chromoendoscopy.

00:09:00: But again, using virtual chromoendoscopy entails the fact that you're trained in using it.

00:09:06: You can switch on the button, but if you don't know where to look for, of course, it's useless.

00:09:12: So that's one thing.

00:09:13: Documentation is very important.

00:09:16: And indeed, using caddy might increase the fact, and that has already been shown in the literature as well, that we increase the diminutive polyp detection.

00:09:26: But it's mainly on the left side, and it's most probably a hyperplastic one, also in the literature.

00:09:32: But of course, if there's the fifth adenoma, that gets you in a dual position.

00:09:38: And again, I would then discuss it.

00:09:40: if there is like an An agreement between you and the pathologist for, okay, this is a fifth adenoma.

00:09:48: I think you should apply what we currently use.

00:09:51: Of course, in case there isn't a mismatch between what you think as an endoscopist and what the pathologist thinks, I think... at least, but it's my personal opinion.

00:10:01: I would again discuss it with the patient and maybe re-scope the patient one more time in an earlier interval than the ones without that.

00:10:12: But you know, if you

00:10:12: have... He's evading a little bit the hepatitis.

00:10:14: Yeah,

00:10:14: I would say it's

00:10:15: like... What about... The question is, should we change the guideline?

00:10:19: Because we do a better job.

00:10:20: We use the endocom.

00:10:22: We use the AI.

00:10:23: We do the best bowel prior.

00:10:24: We take our time and look at everything.

00:10:26: The question is, what's the clinical impact?

00:10:27: So now we found ten polyps and... We find ten polyps instead of two, which we, in the low quality endoscopy, we might have missed eight.

00:10:35: And we see the patient back in ten years.

00:10:37: We do a very good job.

00:10:38: We find ten and we see the patient back in three years.

00:10:40: So this is a paradox somehow that we need to solve in the future guidelines, no?

00:10:44: What do you think?

00:10:46: Yeah, well, currently I wouldn't change it because we know the data up to today and it's not in there.

00:10:51: And of course, This will be considered during writing these guidelines.

00:10:55: But as Veronique says, the clinical impact of finding these small diminutive polyps is very little.

00:11:01: It's very little.

00:11:02: So probably it won't be cost efficient to re-scope patients after three years.

00:11:08: But please let me keep him still in the corner fighting because you mentioned the report and they say that I'm writing down.

00:11:15: I made a quality endoscopy.

00:11:16: But in this setting, maybe the AI can help us.

00:11:20: about making, let's say, a standardized report, but also proving that you spent enough time on endoscopy.

00:11:28: The preparation was objectively good, not just because you said this might be good, or actually often happened the opposite.

00:11:36: People say it was not good enough, so come back.

00:11:39: But if the feature intelligence say, no, that was a good preparation, you shouldn't reschedule the patient again.

00:11:44: So what do you think?

00:11:45: Should we... Have mandatory the AI in our report or not?

00:11:51: For the future, definitely yes.

00:11:53: But I think the current algorithms aren't well enough speaking of CAD-X because that's what it's going for.

00:11:59: CAD-D has been proven to be implementable and to improve your detection with an overall twenty percent on ADR.

00:12:07: But for CAD-X, there is no such data.

00:12:09: We show that there is indeed some improvement, but also the other way around.

00:12:14: And what it does show is that the clinical impact is not truly efficient.

00:12:19: We do not meet the standards for rese... at this cart, we do not meet the standard for sodac right here.

00:12:24: So we can use it.

00:12:25: There is no harm in using cad-X, but currently speaking, I would not trust the AI to just say, well, this was a high quality optical diagnosis confirmed by AI, and the report is done.

00:12:39: This was all good.

00:12:40: For the bowel prep, that's another question.

00:12:43: There are some good systems, but again, they're very limited, and they're not really implemented in clinics yet.

00:12:48: And Raph, sorry, I want to make you a question, because you are involved in education.

00:12:52: What do you think could be the impact of having AI, at least CAD-E, showing polyp all the times?

00:13:00: And when you switch off, or it's going to be also, let's say, a long-term effect on the detection rate, or it's going to make people more lazy, and the day you don't have the CAD-E system, you are losing actually polyp.

00:13:13: What do you think?

00:13:14: That's a very good question.

00:13:15: And actually, as a matter of fact, at ESG days this year, there was an abstract on that, showing that there is no de-skilling.

00:13:21: So that was the first one, I think, that was quite reassuring with that aspect.

00:13:24: Because obviously, something to be concerned about.

00:13:27: So apparently, people are still finding the way without the GPS, which is good, I think.

00:13:32: So I want to take it back to the optical diagnosis.

00:13:34: So back to you, Vedonik.

00:13:37: So you talked a lot about that.

00:13:41: and this resect and discard or diagnose and leave inside to strategy.

00:13:46: We've been talking about it for almost fifteen or maybe twenty years by now and still it's not there.

00:13:52: So, but there are also some new molecular insights in terms specifically for the hyperplastic polyps.

00:13:58: So, we now can make a distinction between goblet cell rich hyperplastic polyps.

00:14:03: You have microphysicular hyperplastic polyps and especially the leather.

00:14:08: They can harbor more B ref mutations that you alluded to for this radar pathway.

00:14:12: So, some theories that are out there now that maybe we are looking at different histological features in a transition from goblet cell rich to micro-physical or hyper-plastic polyp that may be on the way to become a serrated polyp as well.

00:14:30: So do you think to leave it inside too, is that a good thing to do?

00:14:35: or do you think we're ever going to get there?

00:14:37: or are we going to go more for resect in this card?

00:14:40: What do you think about that?

00:14:42: Yeah, I think you have a good point saying that these strategies are already being under development for maybe even twenty years and even at this moment they're not implemented widely.

00:14:53: There are studies done to question gastroenterologists why they don't implement this strategy in clinics.

00:15:00: They are afraid, they are not confident and the sensitivity that is requested by the SOTA criteria is up to eighty or ninety percent.

00:15:11: to apply this strategy in your clinic.

00:15:15: So that's quite high and I understand that endoscopists don't feel confident enough or aren't confident enough to be able to adopt this strategy.

00:15:24: And with the new data on the hyperplastic polyps or serrated polyps, this is not implemented in the studies on the resect and discard or leave and see-do strategies, but I think this should certainly be taken into account.

00:15:38: So with that respect, the resect in this card is a bit easier, right?

00:15:41: Because you can make an optical diagnosis and maybe, yeah.

00:15:44: And at this moment it will not change.

00:15:45: You might miss the fifth or we diagnose one too many adenoma, where at least it's been taken out.

00:15:50: Exactly.

00:15:51: I agree.

00:15:52: And also the sensitivity there that you need is only eighty percent, while for the leaving side you need ninety percent.

00:15:58: And I don't think there's any catech system that achieves that at this point, Peter, does it?

00:16:02: No.

00:16:03: All right, so going a bit more to the advanced.

00:16:06: and the optical diagnosis.

00:16:07: Fidini, can you explain to us one more time how should people look at these polyps to make a good optical diagnosis if you see something that is three, four centimeters?

00:16:17: How do you deal with that and how much time does that take?

00:16:21: It's important to take time.

00:16:23: to do a thorough assessment, to take time, to document well.

00:16:27: If you're doing the resection yourself, it's important, but also if you want to refer the patient.

00:16:31: So the patient can be referred with adequate documentation, adequate information, so that advanced endoscopists can make a decision on planning.

00:16:40: in terms of scheduling, but also if the lesion looks more suspected than the referral gastroenterologist thinks, there can also still be a change in strategy at the moment.

00:16:52: the patient is referred.

00:16:54: So I described five steps to do an adequate optical diagnosis.

00:16:58: And actually, if we take a step back, you always start from afar, actually, when assessing a polyp.

00:17:04: You look at the polyp, you look how big is the polyp, you assess the location of the polyp, so where is it situated.

00:17:11: And then you go closer and you look at the morphology.

00:17:14: First, you also look from afar.

00:17:15: So this is a granular lesion or a non-granular lesion.

00:17:20: Are there features of submacosal invasive cancer, like a macronodule?

00:17:24: Is there a depression?

00:17:25: And there are all things that you can see from quite from afar.

00:17:29: And then you will go a little bit more closer.

00:17:32: And every time you go closer and closer, assessing the lesion into more detail.

00:17:37: First, with high definition white light.

00:17:41: looking for vascular and surface patterns that are disrupted.

00:17:44: And of course, then you use the virtual or diabetes chromendoscopy to search for lesions or for areas that are suspected for harboring invasive cancer.

00:17:54: And how difficult is it to learn that?

00:17:56: What do you think is the learning curve if you teach your fellows and Limonce to do that?

00:18:01: Is it so difficult or?

00:18:03: experience will learn it.

00:18:04: You have to do it a lot, a lot first together with somebody who has experienced in it, who can correct you, but you can also train during staff meetings with pictures and with experience from others or videos.

00:18:18: So it takes some time to learn it, but I think it definitely it's worth.

00:18:23: to become proficient in a good, thorough, optical diagnosis.

00:18:27: And you

00:18:27: take also a patient, because very often people just say a polyp and say, oh, it's big, let's schedule again and took two pictures instead.

00:18:34: You had to spend many minutes, I hope, but they say, looking carefully and try to see what is the, they say, more disrupted area on the surface, not just now the taking closer picture, because you have also to pick up.

00:18:50: which are the pit pattern or the macroscopic aspect.

00:18:55: that actually will change completely your decision.

00:18:58: This is a matter of patience, especially if you have... eighty eight centimeters or ten centimeters polyp.

00:19:04: you have to document it very well.

00:19:06: that takes

00:19:07: a long time to do a really good assessment of large lesion but in fact also for residents or for gastroenterologists in training every lesion that you encounter also also the small ones you should use them for training.

00:19:18: is this a hyperplastic polyp?

00:19:19: this is an adenoma.

00:19:20: you should train yourself just looking at the lesions with white light with virtual chromandoscopy.

00:19:25: so every opportunity you should use to to train yourself in this.

00:19:29: But I want also to address, because we are speaking of artificial intelligence, chromaendoscopy, and high definition.

00:19:35: But at the end, everything depends on the quality of the preparation.

00:19:40: Because even if we are in Leuven, and we have all the technical devices, and you are very skilled, but then the patient arrived and is poorly prepared, then you wasted a lot.

00:19:51: The patient had, of course, discomfort in coming there.

00:19:54: And you cannot even professionally try to look at this polyp.

00:19:59: How do you think we should manage the patient and also the bowel preparation?

00:20:03: Do you have any tricks and tips that can you tell us?

00:20:07: I think the most important message here is that you cannot just give the appointment to the patient with the instructions and say go ahead, read it and do what's written, right?

00:20:18: And that is really crucial.

00:20:19: I think just spending five minutes with the patient to go through the bowel preparation and give clear instructions, you know, with a timeline, then you take the first dose, then you take the second dose, depending on when your colonoscopy is scheduled.

00:20:34: It's really important.

00:20:35: So I always put it to the patient like this.

00:20:37: I say we do our best on our side.

00:20:38: We make sure we do a safe endoscopy and high quality endoscopy.

00:20:42: But this is your part of the job, right?

00:20:44: So they need to be.

00:20:45: they need to feel responsible for that part and understand the importance of what you just said, an excellent bowel preparation, because all the rest doesn't matter if you don't start with a good bowel preparation.

00:20:56: So these five minutes, either by you as a physician or a trained nurse, are really crucial just to make sure you communicate that.

00:21:04: And also to the GPs that might be watching this training, I think it's really crucial to take the time to explain that, because if they just make an appointment on the phone and the endoscopy unit and just say you can go there.

00:21:18: The patient may even show up without preparation.

00:21:20: So that's a shame because they take time off of work.

00:21:24: They come to the hospital and so it's a big burden on your planning.

00:21:28: It's a big burden for the patient.

00:21:29: So it's really I mean it seems trivial but it's so important.

00:21:32: You should create a virtual gastroenterologist that can

00:21:36: discuss

00:21:36: with the GP and with the patient how to be prepared.

00:21:40: And this is on top of even digital apps you know or or SMS services that patients won't, oh, just remember you have to start your diet now, or now it's time to start your first dose of the bowel prep and so on.

00:21:52: I think this is what we showed in the presentation, but it all starts with some simple instructions and good graphics that you give to them to make sure they know what's going on and what product they need to take.

00:22:04: Do you think there are also some aspect that should be taken into consideration, not just... the patient compliance with the preparation, but also I'm thinking about comorbidities or other factors that could influence the patient, but also your choice for the bowel preparation.

00:22:19: Yes, absolutely.

00:22:20: I think these are really crucial factors.

00:22:22: So we also need to always need to reconsider or consider the fact that patients may need to do this investigation again.

00:22:30: And I think the data that you all showed here, especially with regard to interval and the risk of post colonoscopy, colorectal cancer, that really indicates that if we want to prevent cancer and we find metabolic polyps, then the patient needs to come back.

00:22:43: So if they have a very bad experience from the start, and if you actually ask them, most of the burden is the bowel prep, so I think we need to look at the evidence that most patients actually prefer low volume.

00:22:55: So I think this is the first thing to start.

00:22:57: And then you need to see, it's all about tastes.

00:22:59: So we cannot dispute that.

00:23:01: It's a nice Latin saying about that.

00:23:04: But that's the first part.

00:23:06: And then the second thing is then the comorbidities.

00:23:10: I think the first thing to question yourself is, does the patient really need a colonoscopy?

00:23:14: If we're talking about somebody with severe rental failure or severe cardiac mobility, low ejection fractions, we always need to discuss with the referring.

00:23:24: physician, is this really necessary?

00:23:26: This is an invasive procedure.

00:23:28: The bowel prep may be dangerous for the patient.

00:23:30: So if they still need it, I think the best way to do that is then, unfortunately, go for large volume but isotonic pack solutions.

00:23:37: I think they are the safest in terms of electrolyte disturbances.

00:23:42: Another difficult... group I think is the ones with chronic constipation.

00:23:46: because if you look at all the trials for bowel preparation none of them actually include patients with constipation.

00:23:52: they're always excluded.

00:23:54: even if they are on systematic one pack back per day especially if they are on prokinetic they're all excluded.

00:24:01: So all we see in the studies does not apply to the population who is on chronic laxatives.

00:24:07: So here you need to think twice.

00:24:08: And what you need to do is first see how is this tool movements in these patients per week on their therapy.

00:24:14: If this is like every day, probably you can prescribe a normal bowel prep.

00:24:18: If their past tools only once or twice per week.

00:24:22: Then maybe you need to reconsider how you do this and maybe add some Isotonic bowel or perhaps the days before or increase the laxative therapy the days before and then go ahead with the bowel preparation.

00:24:35: And what about prokinetics?

00:24:37: Yeah, there's no data about that.

00:24:39: I think to prescribe for instance procelepride is probably very expensive for them, because it's a seventy euros for a box.

00:24:46: In the

00:24:47: beginning, you also set effects.

00:24:49: But if they're on it, you can always increase the doses, maybe, or if they take it on enough, you can say, OK, take it systematically.

00:24:56: So what I want to say, basically, is they need a personalized approach, and you need to take this in consideration.

00:25:01: You still may go wrong.

00:25:02: In the worst case, if they need very large volumes, we even provide a preparation through a nasogastric tube, where we can even add six or seven liters.

00:25:12: but that is done on an inpatient situation, I think.

00:25:15: I don't know how you approach this.

00:25:17: No, yeah, it indeed depends on the setting.

00:25:19: If they are inpatient, they actually need extra care because we notice that their preparation is very often, not always, very often is worst.

00:25:32: even if there are nurses, twenty four hours per day next to them and because probably low motility and comorbidities, that's why we make, sometimes we try to double or at least to increase the dosage of the preparation.

00:25:48: And just thinking about the therapeutic aspect, so if you are planning to remove a big lesions, are you doing an extra preparation to be sure the bowel going to be Perfectly clean or you just take to the tradition?

00:26:02: in general we do a standard preparation Of course also personalized if there is.

00:26:09: if there is if it's if it's necessary to do to give a higher dosage.

00:26:13: But in general we give a standard preparation also for the rectal lesion.

00:26:18: so for rectal EMR or ESD the patient should take a Complete preparation

00:26:23: so some more safe.

00:26:24: Yeah,

00:26:24: exactly fair.

00:26:25: Yeah,

00:26:26: okay, so Manuel, you also talked about screening and how this actually affects maybe colorectal cancer, mortality.

00:26:35: I may actually challenge you a little bit on that, because we had the Nordic trial, I think already two years ago, Peter, if I'm not mistaken, right?

00:26:43: And that actually didn't show effectively a decrease in mortality.

00:26:49: There was a decrease in colorectal cancer as such.

00:26:53: Does that still hold?

00:26:54: Do we still need to do screening colonoscopy?

00:26:57: And then what modality should we use at this stage?

00:27:00: Should it be fit based?

00:27:01: Or should we go for primary colonoscopy screening?

00:27:05: Can you shed a light on that?

00:27:07: Well,

00:27:07: first of all, there are data about the fact that using the fit test, actually, increase the adherence to the program, to the compliance, because as you said, patients are still scared about colonoscopy, first because they think it's a painful examination, and that's why I stress the fact that sedation is really a game changer in the last decades.

00:27:29: And another aspect is the bowel preparation, and even if they didn't feel anything during the endoscopy, they are scared to redo again the preparations.

00:27:41: And there is also some confusion about the fit test.

00:27:44: Some of them say, OK, I have done a colonoscopy.

00:27:48: Then the year after, they already repeat the fit test.

00:27:53: And if it's positive, they get stressed about, oh, then I should redo a colonoscopy.

00:27:58: And so the point is, we, first of all, must be aware that the fit testing is perfect.

00:28:02: So it might be false positive.

00:28:04: But as a strategy, also to save some money, The fit test is still, let's say, useful tools, at least, if not powerful, but useful because increased the patient awareness about the risk of cancers.

00:28:22: And there is also data that inviting patients for, let's say, just have a colonoscopy or decide to screen the patient with the fit test first, actually provide a non-inferiority results for the fit test and increasing the... adherence.

00:28:41: And another aspect is that we should increase our capability to predict the risk of the patient because as I said at the moment it's not possible to say you cannot undergo colonoscopy because you are going to be for under percent without cancer in your life.

00:29:01: But as you said, maybe digitalizations and the possibility to get access to the personal information for also big data analysis will improve this knowledge.

00:29:12: And the way we are considering the selection of the population will be changed.

00:29:17: But for the moment, I will stay with the fit test age, so older than fifty years old.

00:29:24: eventually think about the forty five years old.

00:29:26: I was about to ask you that.

00:29:27: I was

00:29:28: trying to avoid that age question because it's still an increasing.

00:29:32: the cost and the amount actually of cancer that is going to be reduced are quite low.

00:29:38: Right.

00:29:39: And especially if you as you mentioned that the end the mortality is not going to change.

00:29:45: So why are we doing that.

00:29:46: No.

00:29:47: So this is still a thing something we have to work on.

00:29:51: One might argue Peter that.

00:29:52: despite the fact that we don't decrease mortality.

00:29:55: Maybe that's because of the better chemotherapy we have nowadays.

00:29:58: So it's still a large burden on society.

00:30:01: No.

00:30:02: I imagine I think the chemo.

00:30:04: Well, chemotherapy is I don't think is the problem, but it's more the immune therapy and the biologicals they start using, which are very good therapies in certain cases.

00:30:13: But they are also quite large burden on the socioeconomics of your country.

00:30:18: But of course, the digestive oncologist used that trial to say, well, why still screen with colonoscopy?

00:30:24: Because our treatments have become so good that patients don't die anymore from their colorectal cancer.

00:30:30: And you have to give them that.

00:30:31: Partially, that's true.

00:30:32: But of course, using therapies with two thousand euros a month.

00:30:38: also gives you a large burden.

00:30:39: That's

00:30:40: still that's pretty cheap.

00:30:41: what you say there is probably more.

00:30:42: Even that is already quite quite expensive for for a society I think.

00:30:48: So yeah it's a discussion we have to we have to make.

00:30:52: But I believe screening fit based is still the first way to go.

00:30:59: Although your cancer mortality doesn't really decrease by it.

00:31:04: Okay, so that brings me to the last part of this round table.

00:31:07: It's the organ preserving revolution.

00:31:10: We have it throughout the GI tract.

00:31:12: We have it upper GI.

00:31:13: The Japanese has pushed this very much with their ESD.

00:31:18: So first to you, Peter, I mean, you've been talking about AI and we saw how difficult it is to detect or to make a correct optical diagnosis.

00:31:27: I really estimate, okay, is this a submicrosal invading lesion?

00:31:30: Is this a T-two cancer?

00:31:32: Do you envision that artificial intelligence will be effectively helping us in selecting patients better for the correct therapy?

00:31:39: I think so, not for now.

00:31:42: I think current systems aren't capable of doing that.

00:31:46: There are reports of algorithms capable of assessing submicosal invasive cancer with good accuracies but not... optimal.

00:31:55: But I think as Manuel already said that it all comes down to risk stratification.

00:32:01: And so there are already some NLP systems that are capable of detecting cancer throughout just medical files using medical files.

00:32:11: Before we even as a physician know that these patients are at risk for a certain cancer.

00:32:16: So if we can include these type of algorithms together with very well established detection models, categorizing models and estimating invasive cancer.

00:32:30: I think that will give you a holistic image of the patient and might guide you through a certain management.

00:32:38: But we're not yet there.

00:32:39: But I think the key for that will always be that we have these nice high definition images.

00:32:45: that are almost perfect, right?

00:32:47: So, and I think for everybody who does these interventions, it is, let's say it honestly, very disappointing, sometimes the quality of images that we get, if we get them at all in the video.

00:33:00: So, give some tips and tricks, Widenik, how can we optimize that and how would our patients benefit from a better effort to that aspect?

00:33:11: So it's actually a part of the obstacle diagnosis.

00:33:13: Everything that you see with your own eyes, you should document it with a photo or with a video, allowing external physicians or the expert endoscopists that you will set the patient to, allowing them to do the same assessment as you did.

00:33:30: So starting from afar, going closer, using white lights first, and then chromendoscopy, looking for small areas that are disrupted.

00:33:40: and really taking pictures of every zone, really make a good report describing everything you see, and then referring the patient or discussing it in an MDT meeting, asking advice from colleagues.

00:33:50: Even if you want to resect the lesion yourself, it never harms to discuss the patient with colleagues to have a consensus on the treatment and then go ahead with the treatment.

00:33:59: Yeah, because I don't think we can underestimate the effect that has on a patient, right?

00:34:04: Because you do, for the first time, your colonoscopy, And then you see, and you have to tell them, look, there is a big thing.

00:34:11: I'm not really sure what it is.

00:34:12: I'm going to send you to Dr.

00:34:14: van der Voort to have a better look, or to Professor Jeremy Jagd to have a better look.

00:34:20: So they have to wait before they get there, right?

00:34:23: So just those five minutes spent to take those images and that footage can make such a difference because they can send the images to you.

00:34:33: You as an expert can look at it and say, OK, I need two hours, one hour, you can schedule the slot.

00:34:40: And all you need to do is to inform consent, which you can do like in a short outpatient clinic to explain the procedure.

00:34:48: but otherwise they have to come back, you need to prep them.

00:34:51: You cannot schedule the therapy because you don't know whether you need one or three hours, right?

00:34:55: So these five minutes extra make such a big difference for the patients.

00:34:59: In

00:34:59: terms

00:35:00: of what you're going to say to them, you say, I'm going to send you videos to the referring doctor.

00:35:05: They can have a look at it and we're going to decide for you within a week what's going to happen.

00:35:09: Otherwise, you need to get a schedule for a new appointment, new bowel practice.

00:35:12: You lose time, which is also important when... a doctor receives a file of a patient.

00:35:19: The images are also important to schedule the delay of the intervention.

00:35:23: So is it an ugly lesion, then you will plan it as fast as possible.

00:35:27: If it is a benign lesion, but with a macronodule or something that doesn't worry you at this moment, you can plan the patient a little bit further, like in eight weeks or with a more acceptable delay.

00:35:44: If it's a lesion that's already suspect, you should not wait two, three months and schedule it in the future.

00:35:51: So also that, therefore, the documentation is important to schedule the patient at that moment, but also schedule the delay for the planning.

00:35:58: Sorry.

00:35:59: And is the documentation, I'll just be advocacy for the devil, is the documentation of photo enough?

00:36:04: or should we?

00:36:05: biopsy deletions first and send you the report as well.

00:36:09: And secondly, should we mark the lesion?

00:36:11: Because of course, if it's a lesion of sixty millimeters, it's probably not hard to find it again.

00:36:15: But if it's a lesion of about twenty millimeters, because it's always an estimation, should I ink the lesion or not?

00:36:21: So photos and videos, if it's possible, that's what's preferred.

00:36:27: Biopsies are not necessary.

00:36:28: There is a high chance of sampling error that your biopsy... the superficial part, of course, which shows low-grade dysplasia or high-grade dysplasia.

00:36:38: It doesn't exclude that there's cancer or an ulcerated part that you didn't see or in a deeper part of the lesion.

00:36:44: So biopsies are not contributing.

00:36:49: And should you mark the lesion?

00:36:51: Of course, for large lesions, no.

00:36:53: For smaller lesions, if you do a good description with a straightened scope, you describe the centimeters from the anal verge.

00:37:02: In general, we don't mark the lesions and we also don't expect it from referring doctors to...

00:37:08: So basically save the time, not taking biopsies, not putting the inked in and spend that time taking good footage and good

00:37:15: image

00:37:15: and video acquisition and good report.

00:37:18: So I think we can round up the round table here with some... Very nice messages.

00:37:22: Actually, it's a very simple message.

00:37:24: Two times five minutes can change the management of the patient.

00:37:27: Five minutes for good bowel instruction, right?

00:37:30: So they do it right from the first time and you can assess and find everything that is there.

00:37:34: And a second five minutes, if you find something of significance, to really... take the time, those five minutes, good video documentation, discuss it with an expert center, who come to his expert center.

00:37:46: that has all the therapeutic argumentarium that you can offer to a patient and that can really be a game changer for your specific patient.

00:37:55: So thank you very much.

00:37:57: Thank

00:37:58: you.