E49 Masterclass With Clarence Wong On Advanced Polypectomies and Quality Metrics In Colonoscopy

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Chad Ball  00:12

Welcome to the Cold Steel surgical podcast with your hosts Ameer Farooq and Chad Ball. We’ve had the absolute privilege of chatting with some amazing Canadian as well as international guests over the past year. While the topics have been brought in range, whether clinical, social or political, our aims for the podcast continue to remain the same. We hope to inspire discussion, creativity, scholarly research and career development in all Canadian surgeons. We hope you enjoy our second season as we continue to highlight some incredible guests, deliver detailed masterclass sessions on a myriad of clinical topics and introduce some fresh new features such as debate and companion formats. We hope you relish the podcast as much as we do.

Ameer Farooq  01:14

This week on the podcast, we were lucky enough to be joined by Dr. Clarence Wong. Dr. Wong is an interventional gastroenterologist at the University of Alberta in Edmonton, Alberta. And he gave us a masterclass on his approach to large polyps and polypectomies. In addition, we talked about a number of other work that he’s done around screening guidelines for colon cancer, as well as his many simple yet super effective tips and tricks for improving the quality of your colonoscopies. As always, we look forward to your comments, thoughts and suggestions. Dr. Wong, thank you so much for joining us on Cold Steel. And it’s really an honor and a pleasure to have you. You are the first gastroenterologist we’ve had on this surgical podcast. So please tell us a little bit about where you grew up and in your training pathway.

Clarence Wong  02:08

Yeah, well, thanks so much for having me. I’m really honored to be the first guest enterologist on and I know hope my I do the rest of my colleagues, some service but I actually, some of my colleagues knows but I grew up in Calgary and so if I can relate back I watched the Flames playing the Corral. I was volunteering the the Olympics in Calgary, so I am so called Alberta boy. But I did come to med school in Edmonton at U of A, and then I did my internal medicine at McMaster and I think that was really important because I really learned some strong fundamentals about evidence based medicine before coming back to Edmonton to do gastroenterology in terms of the fellowship, but afterwards, I did a number of years in at the Cross. So I did oncology, not only in a wet lab for some time, and then I also did therapeutics, endoscopy, some in Edmonton, but some of it was in was in Quebec learning ultrasound. So I’ve been around a few places. So it’s been it’s been nice and I’ve been very lucky to have trained in multiple areas.

Chad Ball  03:15

It’s so true. We talk about that often on the podcast, how helpful it is to do different components of your training over time in different places, just to you know, I mean, meeting people is one thing, but just seeing different ways that things can be done. Expand your your brain I think for a career, there’s no doubt. My biggest question for you Dr. Wong is are you a Flames fan? Are you a Oilers fan?

Clarence Wong  03:37

Oh, hold on. I’ve got red in my closet.

Chad Ball  03:40

Oh, jeez. You and I are flipped. I grew up in Edmonton and of course now live in Calgary and I cannot cheer for the Flames. For the life of me. Just can’t do it.

Clarence Wong  03:52

Although I have softened, because you know, when you live in a place long enough.

Chad Ball  03:56

Your kids?

Clarence Wong  03:57

It it gets to be one and two, my my kids are Flames fans actually, they were born in Edmonton. So it’s actually quite quite interesting. But I totally agree with you. I think for trainees, I tell them the most important thing. And the biggest luxury that you have training in, in Canada is that you have access to different places you have access internationally, I think we’re really lucky. And I always tell someone that if you train one place, I always see that as No, just a little bit of a question mark, obviously, you can be great, but you know, there’s just so many different points of view. And I think it rounds you as a professional when you do it that that way.

Chad Ball  04:28

Yeah, professional and a human being is no doubt. You know, you’re very well known not only provincially but nationally for a whole bunch of things. But one of the things I particularly wanted to touch on was the screening guidelines for colorectal cancer not in Alberta, in particular your view and the evolution of the FIT test from the FOBT traditionally, so I guess how did that come about? What are those guidelines look like and give us a sense for for us, you know, a silly general surgeon like like me how good that FIT test really is. In other words, I remember one of your talks you had mentioned, you know, if your FIT test is positive, you should find some sort of lesion this this proportion of time.

Clarence Wong  05:09

Right, right. So it’s, you know, it’s it’s within our short careers that people forget how poor colon cancer screening rates were. So I was reviewing some of my own talks. And back in probably 10-15 years ago, the 2005 kind of report card of colon cancer screening, Alberta was at about 25% of the target population for screening like that is just astoundingly terrible in terms of a disease that’s completely preventable. And as we all know, every colon cancer, from my point of view is almost a preventable disease. So if we jump forward now back then it was it was kind of, you know, do a little bit of FOBT guaiac, do a little bit of endoscopy, maybe doing some some barium. And I think at the end of the day, it confused everybody, and no one got screened. And so for the last probably the next probably 5-10 years after that we knew that FIT or fecal immunochemical testing  was available. It wasn’t quite in Canada yet. But in Japan and Europe, they’re using it. And from some of their literature, it was astounding to see the the increase. So we actually brought over a number of experts. One I remember was Graeme Young was from Australia, who runs the Australian program. And he really just gave us the pearls and and kind of the whys because, as you know, a lot of us in terms of GI in surgery, were saying that we should just stick to colonoscopy. It’s the gold standard, why would you even look at something else. But though the most important screening test in any field is the one that gets done. And I think what we forget about guaiac and colonoscopy is that, number one, the FOB guaiac, patients didn’t like to it, it was on three separate days, you couldn’t have certain dietary things and do it. And the other problem is the colonoscopy is obviously it’s access. So if you weren’t on a colonoscopy model, sure the person in front of you or the one that lucky to get the scope would get screen, but a large proportion of the population wouldn’t. And so the FIT was actually a good answer to that. It was certainly the sensitivity wasn’t as high as colonoscopy. But it was it was miles better than a guaiac. And the patient’s preferred it so much, it was so much easier, as you know, one test was done. And the overall kind of the accuracy rate on one test was 80%. And so if you did that, over time, the the FIT test was was actually very accurate and picked up a lot of lesions.

Ameer Farooq  07:46

I think one of the interesting things that you mentioned is that when you’re making these screening guidelines, it’s not just, you know, how many colon cancers have we prevented? Or how much more you know, preventable mortality? Have we averted? There’s all these other considerations that go into it. Like, you know, how easy is this for patients to do? Or how easy is it for patients to get access to this test? You know, there’s, there’s, there’s a ton of considerations that must go through your head and everyone else who is involved in making these screening guidelines. Can you talk to us a little bit about what are the considerations that go into making screening guidelines like this, on a provincial level, like mechanistically? What does this look like? What are the considerations? And you know, how does this get rolled out?

Clarence Wong  08:36

Yeah, that’s a great question. And I think it’s one of those things that if you asked me, you know, 10-15 years ago, probably when I was much more naive, it was no look at the evidence and follow the evidence. That’s what I would have said. But the truth is, there’s many things that when you look at the evidence, you also have to realize is it applicable to your zone? Is it is it doable from both a professional point of view from your endoscopy community, and also from primary care? And so I think, you know, when we actually start to form and look at the the committees and the guidelines, that stakeholder input was so critical. And as you both know, you look at the evidence, the guidelines, there is room to shift and, you know, my teachers back and back when they taught me, the same thing says, not everything is an RCT. And in fact, most evidence out there is not an RCT. So you have to realize how to make it the best, you know, applicable and useful for your group. And so when we were designing this, I think, you know, having primary care at the table, having you know, patient groups and then hearing their voice, having community and also academic endoscopist, I think the that set of voices in and everybody had their viewpoint but how to actually streamline that together to make one uniform set of guidelines was really important. Now, now the FIT, we knew the evidence was strong, and that was, you know, trying to convince people. But even going back to what Dr. Ball had asked about the pickup rate, so we know that when your FIT test is positive, the chances that you’ll find at least an adenoma is about two thirds of the time, which is astounding. And so I know that when we started the test, we had a whole bunch of people that were finishing the colonoscopy, and then they would go back and do it again, right away and go to see come say Clarence, I didn’t find something I was worried. And this is a 50 year old with a first time positive FIT. And so it changes the perspective of the endoscopist immediately. And the second part is, again, listening to the public is that if you gave it to them, and they didn’t like it, then your test doesn’t matter what the sensitivity is, they actually had to to do it. And what we found is that the patients by far when we did the comparison studies, were much more willing to do this test at home, it still has a little bit of a yuck factor, because it’s a poop test. But you know, the way that we advertised and that’s the one part that I really learned as part of the screen program is that what were our advertising tactics, you know, what were we doing in terms of design. And so I learned a lot from our designers, and people that are are actually actually in in arts and public health. And so again, it was a blend, I knew what the the strong evidence was, but I think it was all these other groups that actually were really important to make, you know, the the guidelines complete, and actually make it so that it’s accessible. And I think that was part of the reason that I think, actually, Alberta, we’ve actually done really well.

Ameer Farooq  11:41

Well, one of the things we’re going to touch on a little bit, is the fact that the US Preventive Task Force has now lowered the screening age for average risk individuals to the age of 45. And, you know, I guess there’s two parts to this one is sort of building off your, your, your answer to the last question, which is, what are the sorts of things that you think about now, when making a shift like that, like, for example, where does cost fit into the screening guidelines? Cuz I’m sure that you know, any of these changes that we make, have a cost associated with them? And has sort of how do you think about that? And how do you sell that on a provincial level? And then the second part of that is, is specifically about this age 45? Do you think that’s sort of the way that we should be going in Alberta as well?

Clarence Wong  12:31

Okay, so yeah, so two things that are so so first of all, it was the ACS that actually made that recommendations for the American Cancer Society. And so they published actually quite a controversial guideline. And with that, they actually showed some data showing that there was a, it looked like a time shift over, you know, that younger individuals were getting cancer. And so they actually made it was very odd and very confusing. They made a conditional recommendation. And you know, I don’t see that too many times in guidelines. They said, we conditionally recommend that you start at 45. So in other places, among the big GI societies in the US, in Canada, every province, including the Canadian Task Force, we still at this time stuck with 50. So I just published a review with academic primary care with Mike Kolber. And we actually looked at Alberta data and compared it to a number of other studies. And so what it does show is that there is a relative increase in that younger group. However, when you looked at the absolute numbers, the absolute numbers were actually quite small. They’re, you know, four or five per 10,000 at most, and actually actually maybe I even misspoke, it might even be even smaller than that. So again, linking back to your cost question is that yes, we could start at 45. But for the number of people that we would have to screen, and that we would actually have to, you know, have FIT tests and go through colonoscopies, that same amount of money. If we apply that to 70 year olds and actually encourage them to get screening, we would actually save the system 10 times more trying to encourage the 70 year old group to actually get screened. And so those are things that we do look at, you know, it is, you know, being an endoscopist is taking a different part of my brain and being part of the public health kind of brain is you do have to say what’s the best for you know, that the system. The other part about colonoscopy, which is, as you know, is different from doing mammography, mammography screening for breast cancer is that every endoscopy may potentially take out a case that’s for diagnostic care, you know, somebody with colitis or somebody with, you know, bleeding in so it’s really important to balance that those two apart and that your screening programs aren’t actually taken away from diagnostic and therapeutic care. And so I think all of that you got to try to find the balance is what’s the most bang for your buck in terms of the age and what’s the best that you can do to ensure you know, as much safety as you can for the public. And I think that’s what we’ve been trying to balance. And it’s an ongoing thing. You know, this is something that when it came up, now we chatted across the country at every with every other screening program to get everyone sense of where we were going. And I think right now, we all are agreeing that we’re seeing the slight trend, but it’s not enough we think to change the guidelines in Canada.

Ameer Farooq  15:24

It’s such an interesting and fascinating area to kind of think about. I didn’t want to specifically while we’re still talking about screening guidelines, one of the things that I think gets confusing for trainees specially surgical residents setting for their Royal College exam is kind of getting their mind around intervals for for screening. So let’s say, you know, you’ve done a colonoscopy, you’ve found a certain number of polyps, a certain number of types of polyps, and then you’re trying to figure out what the interval should be for a repeat endoscopy? Is there a sort of a an approach that you have in your head that you teach trainees that that helps people to remember this? And are there any helpful sort of guidelines or, or resources that you point people towards?

Clarence Wong  16:13

No, a great question. I think that fundamentally, to make it a little bit more binary to start with, is we recommend that you when you actually remove or see polyps separate into low risk, kind of polyps adenomas, and the high risk add gnomes or polyps. Now, I think once you have that split, it really, it’s actually separating even in the further in terms of how you manage these patients. So the standard you know, you see a patient with a six millimeter add Noma. Now that’s a low risk, add Noma and, and actually, the evidence is showing that the high majority of the time, even if you never move that polyp, you probably did change that person’s lifespan. And so even though you might feel great, okay, I took off into one or two, these little polyps, frankly, they probably don’t. And in fact, the guidelines are shifting for that is that if it’s a low risk abnormal, again, it’s less than a centimeter, there’s only one or two of them. And the patient has no other family history are the risk factors, a lot of places around the world are actually shifting to the next interval being in FIT screen. So in Alberta, the current guidelines are still if you see a low risk, abnormal repeat and a colonoscopy in five to 10 years, so even a longer interval. And in Ontario, they’ve actually made the switch to say that if you remove the low risk, add Noma, just go with FIT testing, and five years. Now, it was controversial in Ontario, certainly a lot of people were shocked to move that way. But if you actually looked at the evidence, the amount of life years that you would gain from repeating colonoscopy, that’s it every five year intervals, it starts to actually get into a point where are you actually, you know, causing someone to enter the system more and potentially complications rather than saving the saving them the risk of colon cancer? Now, the most important thing again, the other part again, of the binary said is the high risk abnormal, the high risk polyp in so I make all my residents you know, right from the first year that I see them memorize know, what’s a high risk, add Noma. And there’s a couple of criteria, you know, it doesn’t have anything that the pathologist says, is high grade dysplasia, or interim equals A carcinoma, is it over a centimeter in size? Are there three or more than PR that you found during the time of colonoscopy? And do they have any villus elements. And once you have any one of those criteria, most of the guidelines would tell you that that’s a set that you have to be more careful about. That’s probably a group of patients that you need to bring back at least within three years, if not shorter. So in fact, if you know most of us that see routine, polyps, that actually is the group, you should concentrate on not the one or two small adenomas, and these tell the patient to come back in five years. So we actually did a study in Edmonton where we actually looked at interval rates among g eyes, looking recommendations, and it was kind of all over the board. It was even for the high risk lesions, a third of them actually brought them back too early. A third of them were at the right time, and a third of them. And to me, the most curious stat was a third of them were late. So I really think that the education is again, low risk or high risk, and then make sure that those high risk ones come back early. And anything that’s over two centimeters is an advanced lesion. And that one is that if you’re doing any sort of piecemeal resection, or that he needs to come back within six months, and there’s many guidelines for correction housing, that if it’s over two centimeters, that’s flat, you should be sending to endoscopy, so it actually has extra training. And so that’s something even within the GI community that we’re trying to stress.

Chad Ball  19:44

Can I ask you in particular about serrated adenomas, and how they may be differ from run of the mill adenomas?

Clarence Wong  19:51

Right. That’s a great question. That’s probably one of the most confusing things that’s come up in the last 10 years and actually I’ve given a number of talks in to primary care because for primary care office and they’re starting to see these reports come through as oh sessile serrated adenoma polyp what what is this and how to deal with it. I think the significance of the SSP or SSA as we’ll call them is that the they are funny is that they do have some elements that look like a hyperplastic polyp, but they actually do have some some areas that actually look like a adenoma, if that’s why if there’s a crossover, but the the main issue with them is that when you look at studies that actually look for full resection and recurrence, SSA, these sessile serrated adenomas always have higher remnants in so it’s actually quite scary. There’s one study done that even you know, if you’re looking at residual polyp, when you’re moving an SSA over a centimeter a third of the time, there’s going to be some remnant pulp left. And so it needs to be taken, you know, with a higher degree of you know care. The other thing about SSAs is is that we think that the probably are linked to those higher rates of right sided colon cancer, they tend to be flat, they can be very hard to visualize. And if your bowel prep isn’t perfect if you don’t, you know if you’re not nice and careful that’s one of those things that you’ll miss. And even in those cases where people asked me about even things like CT colonography, I said, well, you know, the one issue with a CT is that they would absolutely miss sessile serrated adenomas, because they’re so flat. And this is where really careful endoscopists that’s taking their time that that’s the best defense about finding these lesions. We find that I think for most people that are looking for these, you have to make sure that you wash the the the lining, well, they can be covered mucus, and you just think it’s a bit of mucus, and underneath is a large flat polyp.

Chad Ball  21:49

You know, since you you mentioned it, and we were gonna ask specifically about CT colonography. Where does that fit in, in general in terms of test performance, maybe beyond serrated adenomas? And then I’m also curious what the variability, if you if, you know, sort of across the country would be in terms of using CT colonography. And the reason I ask of course, in Alberta, it’s extremely challenging for a primary care practitioner to order that out of the gate, it’s where it has to come through GI or through surgery to to obtain.

Clarence Wong  22:22

Yeah, that’s a great question. And I remember back in M to the Cross, we were one of the first centers that have CT colon. And you know, that was again, you know, probably 10-15 years ago and the funny thing is, we used to do a case you go home, you let the computer chug for eight hours to generate one set of images. And then my joke is you know, Pixar came along with you know, higher chip speeds and computers and now you’re flipping these you know, so much faster. But I still think you know, if you look at the the, the evidence going back, if it’s a no polypoid, no a pedunculated polyp, something that has a good sessile NASS, CT colon is pretty good at picking those up. And so most of the guidelines will say, you know, something that’s over six millimeters in size, and at least sessile, the rates of confidence are actually not bad, they’re actually pretty good. Again, the the biggest downfall has been, you know, these these SSAs, and we actually think that the SSAs are a big cause of probably right side of cancers. Now, in terms of across the country and kind of accessibility, you’re right, it does vary quite a bit. And in most cases, I would say that we’re recommending CT colon in cases where the optical colonoscopy is not possible. So very redundant bow, you can’t reach the right side. I’ve had a couple patients that are have had radiation and stricture the the left colon and you can’t see, I think those cases for sure. But in terms of that other sense, if you’re going to order it for screening, I don’t think that we’re there yet. I don’t think many places around the world would would actually reach for that as a primary tool. Some societies do recommend it, that’s one of your no mix of possible things. But again, I think unless your standard was really dedicated, and had radiologists really committed to that, you know, sticking with a simple plan of FIT, and then colonoscopy is simpler, it’s easier. And I would say there’s more evidence to that. So as you know, to Dr. Ball, but you know, in Calgary, because you can buy your own, you have some patients that are buying their own CT colon. But again, if there’s anything that’s found there reprepping again, because we’re not there yet to have somebody prep for a CT colon, and then have them have their optical colonoscopy at the same time. So those a lot of things that even like discuss this with my patient, they’ll say, you know what, I don’t want to do prep twice. I think I’ll just wait and just do the optical.

Ameer Farooq  24:47

But we wanted to shift gears a little bit and talk about something that we were we were chatting about a little bit before we we went on air, which is sort of how we can maximize the collaboration and the coordination between gastroenterology and general surgery. Because I think one of the big issues that remains particularly a problem, or I should say just a reality in Canada is that most of the colonoscopies being performed across the country are still being performed by general surgery. And, you know, I’m curious about what your thoughts are about how we can improve the quality of the endoscopy that’s being done across the country, you know, like, how much is enough volume in residency for general surgery residents to be confident that once you go out into practice, they’re doing a high quality job and they’re doing good quality colonoscopies? Do you think it’s a is it a volume issue that they need a certain number? Is there are there other things besides volume that you think needs to happen? What are you sort of your thoughts about general surgery training in particularly within endoscopy?

Clarence Wong  25:58

Right now, it’s a great pointed question. To me, for sure, if you look at the statistics and going across, in general surgery takes care of a high majority of patients, not only Alberta, but around the country. And oftentimes, they are also that the main endoscopy is in more rural settings. And so when we were looking at our grid map, where a colonoscopy was done, it’s pretty obvious that what you have to do is you have to make sure that all endoscopist whether it be general surgery, sometimes even primary care GI, are you know aware of the the proper metrics are actually trained up. And I always said that my goal when I was the head of colon cancer screening is that we need everybody, you know, a scale up to to that certain high level. That being said, I do think that in the community that endoscopies are done well. I know that’s generally what I look at the stats. Getting in, I think you’re right is the hardest part. And what I find is that that initial transition from training to the first few years of practice, that can be where it’s trickiest, and it’s hardest for people. So in terms of numbers, no, we bantered around numbers around GI internal surgery for a long time. No, no, some groups like I think American Board of Surgery have more numbers like like 50. Some people up here say you have to have 200. And I think we’re getting away from that, that that straight number because because as you and I know it, when you’re doing a procedure, there are some people that have a much quicker knack of picking it up. Some need more time. And with, you know, something like colonoscopy, there’s many things, there’s the technical elements. But the other part for me that’s also important is is that visual elements are no even though you can reach the cecum in four minutes, are you or do you have enough of a visual history that you can actually pick up lesions and to me that probably is is more of an important skill that you learn over time. So I think what we’re moving to, and I’m sure surgery as well, I was just on, you know, meetings this week is is really competency by design and observe colonoscopy. And I think that’s a much better tool to actually assess how somebody is doing. So for example, for our GI trainees, now, we’re actually looking at a number of really set metrics, not just numbers. So we have a trainee, if they, for example, did 100 colonoscopies, but their tip control wasn’t still good. We’re actually using that as a metric to say, you know what, we’re not going to pass you on this level yet, until you can actually show that you’ve got some better tip control, you’re not, you know, pushing a lot of redundant scopes that you’re actually are showing the ability to stay centered. So I don’t know exactly how surgery’s thinking to this. But I really think that that’s, to me, an evening field among all different groups that are doing endoscopy is that we should be actually assessing competence. And I think any experience in endoscopies whether you’re in general surgery or GI, the other pretty good idea when you watch someone doing an endoscopy, whether they’re going to be competent or not. And then to really break down so you know, it’s what I call conscious competence, right? As being said, as do you know what you’re doing that’s good? And do you not know what you’re doing is good? And then the other way around that you know, what you don’t know, you don’t know. And so I think we were teaching now and I’m assessing trainees for endoscopy, those are the things that I’m trying to, you know, tell them teach them is that, you know, do you realize that, you know, you’re you weren’t looking at that step or you realize that you may be a little bit fast and juicy enough. What do you think about that lesion? You know, could talk about that quickly for a second. And so I think we’re probably going to move past the straight numbers thing, because and in fact, I think if we do that, well, among all endoscopists, you know, we’re gonna be training much better endoscopists, whether they be gastroenterologist or general surgeons. So, I think, you know, I was quite I would say, I was not skeptical, but I was on the fence about the competency by design. But actually, now that we’ve got a few years and I’m training the GI residents, I feel that I actually am a little bit more on top of them in turn, in terms of actually giving them direction instead of just saying, Oh, you know, what, what are your numbers today? And you did six? Okay, that’s okay.

Ameer Farooq  30:12

This is a maybe a bit of a controversial or difficult to answer your question. But I’m curious if you if you have general surgery residents come rotate with you, and do scopes with you? And what do you think are the big things that maybe differ in the way that GI sort of approaches scopes versus general surgery? Or maybe that that distinction doesn’t really exist?

Clarence Wong  30:37

Yeah, I think that’s a good, good point. So we used to train a lot of general surgeons doing that, in fact, that was one of our other sites. You know, one of the pride things is that we did train people across. Unfortunately, it’s it was more of a numbers game, rather than, you know, who was training who, we were actually having troubles getting enough time for trainees to come through. In terms of the differences, you’re right, as I think that if you look at how people are thinking about what’s happening in it’s that after part is saying, How are you continuing to improve your skills? How you actually picking up maybe newer techniques? Are you using, you know, the most? Are you using the most up to date equipment? Those are things that, I think are more important than than just looking at how you’re getting trained. So for example, one of the things that, you know, as I’ve done reviews across the province is that I looked at, you know, what, your equipment and I had some places that were using, you know, two generational scope, so I said, it doesn’t matter how good of an endoscopist you are, you’re actually using old equipment, and why wasn’t that part of your assessment of what you were doing? The other part is, I think, when we were having our general surgery residency even come through, I was actually much more adamant to say no, you should do a bit of consults, you know, no look at the cognitive end. And that actually will help you in terms of the endoscopy, because that’ll actually show you, you know, what you’re seeing and how that actually applies back. So that may be the the other big difference is that certainly, if you’re on a GI service, you’re going to see those types of pathologies that you might not see on just the general surgery service. And so I actually think that if we could to have endoscopists go both ways. I also said that the other going the other way is that I really wanted my GI residents to do a bit of a general surgery rotation, I thought that I was actually really helpful for that group that did that as well.

Chad Ball  32:42

Yeah, that’s that’s, that’s well said. And it speaks to collaboration moving forward, which, you know, I agree with you, I think, is getting better and better over time. Having said that, regardless of whether you’re on the surgical side or the medical side, and you did touch on it a little bit, what are the key quality metrics that we should think of as standard, whether we’re running a colonoscopy program in Timmins Ontario, or Medicine Hat Alberta, or in Edmonton at the U of A, in a big quaternary care facility? What are the sort of the basic minimums, the bread and butter?

Clarence Wong  33:13

Okay, so, you know, it’s really funny, you mentioned that, you know, when I was doing the tour around the province and looking at how people were doing, and Dustin tried to mention that, it’s really a lot of basic things. So starting a database starting to look at what you’re doing. Whether I went to Edmonton, Calgary, or Grand Prairie, one of the most basic questions I asked was, what is your indication for endoscopy? So similar what surgeons are doing for ACATS, you know, we don’t have that yet for colonoscopy, but why are you doing it? And I think if you can start to even answer that and have some principles, that is probably the most important thing. And I think, for surgeons, you’re right, is that you wouldn’t ever think about a surgery unless that indication was absolutely correct. And so why is it a different rule for endoscopy? You know, you really should be sure why you’re doing it before just jumping in. And so that question, even my time has still not been answered. And so one of my big pushes over the last one or two years has actually been pushing that, that indications and that set of coding. And so we actually are going to push that endoscopy is on the ACATS list, and we’re actually looking at that set of guidelines to answer that. So that’s the first of all, so why are you doing it? And you know, is that the indication appropriate? I think the next thing is often most people think about technique in metrics so they think about, you know, cecal intubation rate, time and time-in and timeout. But obviously, the other part is, is that it doesn’t matter how many times you hit the cecum or how many know how fast or slow your if you’re not detecting cancers, you know, that by itself, it doesn’t matter what what your level is going in. And so the basic kind of technical things that we measure for most people are is how many times you reach the cecum? You know, obviously, what’s your complication rate? What is your sedation rate, because we’re moving for that. And then on the other end, which is the more difficult part is looking at what you’re finding. So what’s your adenoma detection rate? If you don’t have a pathology report to go through, what’s your polyp detection rate, and at the end, the most important part as part of a screening program, it’s what’s your cancer detection rate. We actually looked at a little bit differently, we issue provincial report cards that we’re trying to replicate. But we did issue a one time assessment of post colonoscopy colon cancer. So these are ones that you would have had a colonoscopy for, but within, you know, six months to three years afterwards that you actually a cancer appeared. So by definition, it might have been missed on that index. But those are the things I think to really think about broadly, for for most people that are doing this, again, count why you’re doing it, look at some of the technical aspects. But then third, look at your results. Because otherwise, you know what, in going back to that, that issue about the volume, some of the people with super high volumes weren’t necessarily the best ones at detecting cancer. And so those things actually have to be separated. And I think we have to be good in all three of those spheres, you know, choose the right patients, do the right technique, find the right lesions.

Ameer Farooq  36:23

I think that’s really a good way of kind of thinking about it. Because I think, you know, even when we when I when I think in my mind about quality metrics in colonoscopy, I’m always thinking about, you know, cecal intubation rate and and ADR but you’re so right, that there’s, there’s step one is who who are you even choosing to do a colonoscopy on, because that’s really where where you, the decision is made is even before they get in the endoscopy suite. You know, it’s interesting, in BC, they’ve started this directed observation of procedure skills, or DOPS, I think I’m messed up the acronym, but basically, they have a program in place where they actually will come and observe you doing colonoscopy, and you have to get that every certain number of years as sort of a as a quality check. And to make sure that you’re sort of up to up to par. Do you think that’s something that we should be moving towards, in Alberta? And and what do you think are the sort of the benefits and potentially some of the the barriers to doing something like that across the province?

Clarence Wong  37:24

Right, yeah. DOPS has done BC, as has been an extremely well. And I’ve talked to their cancer head, which is Dr. Gentile, for I think she’s done an amazing job. And the reason I think it works really well in BC, is that it’s a wide collection of different groups. So it’s not GI its GI and general surgery. It’s not just academic, it’s academic and people in the community. And they actually took some people from the city and some people in rural, so the committee was really mixed. And their mandate, you know, when you’re setting something like this, you got to be really careful what you set your mandate on. Theirs was really more set on improvement in actually skills enhancement, rather than being kind of like the police force, and I’m going to come in and tell you who’s going to be able to do endoscopy, who’s not going to be. And I think when when you set it at that that type of mandate, you know, people that have gone through, and I’ve looked through their reviews, that everyone that comes through this, as you know, was a little bit scary, you know, having two or three your colleagues watch you but at the end of the day I’m a better endoscopist because I got, you know, really good directed feedback. It was good constructive things for me to work on. And it really highlighted to the group that you know, and I think Dr. Ball mentioned this earlier that things change and techniques change. And if you’re just working in your own little center, and nobody ever comes in and actually shows you how something else different is done. How can you pick this up? For me personally, I’m a much different endos, because that was when I finished training. And I would say that every year, I learned something else a little bit new and know some other little technique, even the way that I’m holding an endoscope now is different than I was when I finished. And so these are things that actually have evolved the time. The DOPS really helps that because it’s a really broken down way of how you’re actually positioning the patient, positioning your endoscope. Now what are some real metrics of how you’re actually visualizing the mucosa and so I think that it’s you know, if we can adopt it, it’s a really great way of number one assessing who can come into the system. And number two, that it’s a nice check as your you know, every two to three years to actually do this. The biggest problem with DOPS is cost. I think, you know, these things don’t happen unfortunately for free. You’re you’re taking out some very experienced individuals and you’re having them go to different communities to do this. And so I think that is the biggest challenge but at the end of the day, and if you look at how they’ve done it in BC, every place that they’ve gone through, you know, people have been so happy about the results. And again, if your base thought is that people are good endoscopists and they’re carrying out there and you want to improve them. This is how I think you should do it, you know that you know do have a good DOPS. So in Alberta when we tried to do more multidisciplinary, kind of endoscopy conferences, that kind of the closest thing we have, but I really think that we need to be moving towards a DOPS model is just again, one of the things that I have my list of trying to convince our health authority that no, this is a good investment of money.

Chad Ball  40:29

I think that’s so well said. You know, I, I couldn’t agree more to be quite frank, mentored observation, or whatever term you want to apply to it is, is critical to improvement, but it does require some humility and some self confidence and some willingness to try and get better, you know, I would love for someone like you to come and watch me do a colonoscopy and tweak me in it. You know, I’m, I’m reminded of a really neat article that Atul Gawande wrote, you know, from from Boston, where he was doing an endocrine procedure, and he had a very senior recently retired surgeon just come in, and this sort of icon of surgery was taking 1,000,001 pages of notes, and he was thinking, What am I doing right? What am I doing wrong? And, you know, he beautifully as as only he can do describes that probe that process and that experience and how much it improved his operating. And that was just sort of one exposure. And I I think we all probably should seek those opportunities a lot more than we do. The one of the things you had mentioned was sort of defining an advanced polyp. And I’m curious how you assess resectability for an advanced polyp, you know, with the understanding that you’re a very skilled interventional gastroenterologist with a skill set that not only will exceed, obviously most gastroenterologist, but the vast majority of surgeon. So I’m curious how you look at that. And really what I’m getting at, is if I’m doing colonoscopies in High River, or you’re getting going to go back, Timmins, Ontario, when should you stop? In other words, when should you you pull the chute and send that patient off to somebody like you with with a vast array of skills and knowledge? And to be quite honest, probably different equipment on occasion as well.

Clarence Wong  42:20

Right. No, that’s a great, great question. It’s something that you know, when we cover the conferences, we talk about a lot. And there are actually fairly recent guidelines from the USPSTF, actually on on surveillance, but also, there’s another subgroup that actually looked at polypectomy performance. And from the evidence, it’s really, really clear that if you’re looking at a lesion over two centimeters of size, it should be considered an advanced lesion. And in fact, for in the colon, if it’s know sessile-ish, in terms of there are at least semi pedunculated large that something like that we’re calling an LST, or a lateral spreading tumor. And once you get in that, that range of two centimeters, you should be sending it off to somebody with more experience. Now, even in our community, in our GI community, we’re having a difficulty of convincing some people to do that. But you know, some of the things for an advanced endos was to look at is is number one, just in the amount of time experience we have looking at the lesion. Most of us across the country that that deal with NICO lesions, whether it be in the esophagus, stomach, or colon, so that you know what before we jump in and you’re looking for snares, or whatever else, look at it under you know, careful, high definition endoscopy, use the chromo or virtual chromoendoscopy. Now most people don’t even know where the narrowband imaging button is on their endoscopes. Look at that, assess it. And then think about you know, are there elements may be of deeper cancer, because the biggest mistake I think, for most people is starting a resection, and then abandoning it. And that’s probably the most common type of I would say, a bit of a mistake that I see from the referrals coming in, in the city or from the periphery is that people get into it, and they realize they’re in trouble. It’s never you know, other than the patient’s having to prep again, it’s never wrong to pause to look at it, take pictures, bring it back out, and then just tell the patient know what we got to book this back again, and do this right. I think if you’re looking at a standard 30 or 40 minute time slot, and you’re trying to resect, a two centimeter polyp, almost any expert across the field will tell you, you don’t have enough time to do that correctly and safely. Whereas if I get one of those lesions, I will book off the time to make sure I’m actually just being careful looking at it, and actually using those techniques. So as a good general rule, if you’re looking at assess a lesion over two centimeters, you should be really careful about not tackling at that time. The second issue is about biopsy. Now in the therapeutic field, there’s some kind of it’s a bit of a controversy of what to do. Some of the I think what I call them, the purists, because obviously I don’t agree with them with a no never biopsy, I’m just, you know, maybe tattoo distally and send it off. The problem with that approach is that I’ve had some people send me cancers in so that patients been waiting to see me for one or two months, I take a look. And so I wish the biopsy was done, because that’s clearly a cancer, that’s not a resectable lesion. The other way or the other problems that some people really go at it with the biopsies and the, the biopsy hits so much that they actually tack it down. And so my kind of compromise is, was I’m telling people, they’re looking at these, you know, what, take a look, take a bite of just a one or two bites of the areas that you’re most worried about, if I’m not, you know, close around or accessible. And then like, say, tattoo distally. And that’s actually the other part too. And I think I was doing actually a study with one of your residents in Calgary, there’s a number of people are still tattooing under the lesion, which completely wrecks all resectability planes. And so those are the things kind of to think about before sending it on. The other thing, too, is just take pictures, like take lots of pictures, it’s up to you, you probably won’t be surprised, but I get these referrals, you know large polyp in rectum. You know, what does that mean? How am I supposed to triage that and get a sense from that person should do a full prep? Should I bring them down from you know, again, high level the book for two hours or just put that for 15 minutes for a sake. And so all these things in and in Ontario, what they did is actually did a checklist when you’re looking at large polyps and I think maybe that’s one of the approaches that we may need to take in Alberta as well.

Chad Ball  46:38

That’s that’s very well said. And, you know, again, in full disclosure, that there’s almost nothing worse, I think maybe then being engaged in a colonoscopy and trying to take out something piecemeal. And as you say, being halfway through it and realizing you shouldn’t be doing it. That’s the experience. I think that none of us want to feel at any point.

Clarence Wong  46:56

Yeah, for therapeutic endoscopy. I teach my fellows that just remember, you got yourself into this. So number one, you got to get yourself out of it. Or number two, you got to ask yourself, why did you make that first cut? And was this the right time to do it?

Ameer Farooq  47:09

So we’ve talked a lot about kind of assessing these advanced polyps. I’m curious, we chatted a little bit about this before we started recording again. But you know, one of the things that that was started in Calgary was this advanced polyp committee where big polypectomy or rather big polyps that were being considered either for some kind of advanced endoscopic procedure or for a formal surgical resection or actually being reviewed on a regular basis by a multidisciplinary committee consisting of gastroenterology and surgery, and they would actually review these polyps before a decision was made. Do you think sort of that’s the way that we should be going. And, and in sort of, what are your thoughts about how we can improve our ability to make the right decision on an individualized basis basis for these patients?

Clarence Wong  48:04

Yeah, I totally back that. I think that is absolutely the way to go. Like I was talking with Dr. Ball on this is that in the cancer field, you’d always make some multi disciplinary decision of what to do. You know, before I put an esophageal stents, I’m talking to the radiation oncologist, I’m talking to the thoracic surgeon, you know, who what order what should we do? And I think there’s really no difference with these large polyps. No, they are early neoplastic lesions. I tell my, my fellows when they’re with me that you know what, you screw up the resection, you could have screwed up the planes and all the staging. And so I think the approach right from the beginning has to be multidisciplinary. As well, there’s choice. And I think there’s not necessarily a wrong answer which way you go, you just need to have an idea of which stepwise way you know that you’re going to approach things. So for example, a large rectal lesion like say it could be TEMS, but now we have ESD. So which one, you know is better than the other. And as well, in your center, you may have someone that actually, you know, does a lot of these or not. So I really think that whether it be in the colon for chronic large lesions, or even in the upper GI tract, that you should have a good multidisciplinary team. So for myself, I do a lot of upper GI resections, as well. We’ve been doing Barrett’s and resections of early esophagal cancers for well over a decade, almost 20 years now. But I would say that my most important partner is thoracic surgeries. So we discuss all of these lesions and whether I should do it or not whether they should do it. A lot of times, it’s funny, they’re pushing me to do it. And I’m saying I’m not sure I should be doing this. But I think you need that healthy back and forth to really make the best plan for your patients. And that when I’m telling them and I’m sitting them in clinic, so just let you know, we’ve had about four brains think about your case. And I’ve tried to give you the best recommendation. And so I think the more collaboration that there is, the better outcome there’s going to be for patients. And, and also the other part too is that, you know, I feel like I’m backed up when every one of these cases, you know, it’s not just me, you know, we’ve gone through this, I’ve tried my best, and if you know it goes well, or if it doesn’t, at least you’ve got your team behind you to say, you know what we made the best choice possible with what we knew.

Ameer Farooq  50:21

And it’s amazing how much of surgery and medicine is going towards that kind of model. And I really think that just is so important for us to break down our silos and reach across these traditional divides geographic divides in our minds, so that we can really give the best care for our patients. I know this is this is a big topic, and you’ve given us a great talk on this for the residents in Calgary when I was there. But I did want to get your sort of your tips and tricks for that difficult polypectomies. Can you walk us through when you’re looking at a sort of an advanced lesion like we talked about. What are your sort of tips and tricks on how to approach it and and I want all the details like, you know, are there any positioning tricks, snare tricks, and even even down to things like, should we be using COAG versus cut? So if you could, if you could give us some some tips and tricks, that would be fantastic.

Clarence Wong  51:18

Sure. So you know, so I would say the most common thing that most of us going to see is probably that eight to 10 millimeter polyp. So let’s say the one centimeter polyp and that’s that’s a good polyp, that anybody should reasonably tackle and do well. So I think number one is, again, it’s all about positioning because it doesn’t matter how good you are with your hands or snare if that polyp is in the wrong spot, or it’s sitting in a pool of fluid, you’re not going to have a good resection. I’m referred lesions that say, you know, one centimeter polyp and then it could tell that no, he didn’t look behind the fold. And behind the fold, there’s another three centimeters. And so that’s just a matter of again, that you don’t need a therapeutic endoscopist. Its taking the time to really look at it and to position it well. In most cases, the number one thing that I look at for in a polyp is is try to move it to the six o’clock position that by far is the easiest way with with the instruments coming out of a standard colonoscope. And the next is that if there’s fluid in that in that plane, I will turn the patient in. So use gravity to help you flip it to let the fluid is actually going away from the polyp. And the other part too is that when you resect the polyp, it’s also going to fall into that pool. So it’s not going to sit within the same area. So number one is get your positioning right. The next thing is that again, your choice of a snare you need to really know your equipment. I bug my therapeutic fellows all the time. Tell me what’s there you’re choosing and why. You know, is it a cold snare? Is it thin wire? Is it a medium snare, you know, does it actually have a hexagonal edge? You know, is it just you know, a standard band? There’s such variety now that you know, when I first trained it was like you’re given a snare there’s like the one snare. Now there’s potentially even in a lot of departments that could be five, six, you know seven different types of snares. So choose the one that’s going to fit the lesion that you can resect a lot of time now just to be honest, there’s that I’m using the thin wire cold snares. I think that’s really been revolutionary in this field, it’s really changed how we approach polyps. So even up to a centimeter, a polyp if its sessile, I’ll go at it with a cold snare, I won’t even use heat anymore. So that’s really, really changed. The next point about injection, there’s been a lot of evolution in this field as well. So number one with a large lesion and these are the again two centimeters or more, we’re actually recommending a viscous fluid injection. So if your unit doesn’t have it is Voluven. But there’s actually two commercial products available there was actually in Canada, we’re really lucky to have something called Eleview. And the other one called ORISE. And in all the studies that looked at viscous submucosal injection, you have actually less complications, less residual polyp, better ability to actually resect the entire lesion. For once in the lesion if you think you can do it fairly, you know, with a reasonable amount of time saline is fine but I always tint it with methylene blue. I think to me that that’s a really important step because that little bit of blue tinting helps you see whether you’ve got actually the entire edge and then when you’ve made the cut, make sure that you’re not perforated know that and through through muscle. There is some evidence to show that if you put dilute epinephrine in a 1 to 100,000 it may prevent post polypectomy bleeding. Most one centimeter polyps I wouldn’t do that the larger ones I’m actually starting to do that. We talked a little bit both hot and cold. I’m saving the hots more for against the larger ones but for almost anything a centimeter and under by far in a cold polypectomy with the new thin wires, it is the way to go. And in studies, it’s safer and it allows for a cleaner inspection of the edge. I think you’ll actually leave less polyp. You asked me about the electro surgical unit. So number one, make sure that you are using an electro surgical unit that’s actually computerized, there shouldn’t be too many those old Valley lab type of units out there. And in most cases for the cut, we’re using what’s called the annual cut function. I think that you know, a lot of us that started with COAG. But the problem with COAG is that you can really transmit a lot of energy deep to the muscle. And so the rule is no get the cut first. And then if you have to, you can use what’s called soft COAG on the edges to make sure that you don’t leave any remnants behind. So I think that’s kind of the kind of top to bottom, what I think about for for most approach positioning, and in most cases now, I would say that the cold snare has really revolutionized how we’re actually moving polyps.

Chad Ball  55:51

What are some of the avenues that we can maybe engage in or pursue as average general surgeons to try and improve our skills and improve our technique and improve our endoscopy units, regardless of where we’re located?

Clarence Wong  56:05

Yeah, so I think there’s a couple of things that can be done and certainly in the province of when I was going around trying to help endoscopists get better. And again, it’d be endosurgeon, GI, internists or primary care anyone doing endoscopy. Number one is that in Alberta, we do run a endoscopy skills course. So actually, my co-chair is actually a family physician, my co-chair does endoscopy at a Peace River. And we’ve actually done a very inclusive curriculum. You know, it’s general surgery, again, primary care, some GIs that come. And actually, when people get that, they realize that you know what, the end of the day, it doesn’t matter where you came from. We are endoscopists, we’re all trying to get better. And the faculty that I bring in, they love this group, they said, you know, sometimes it’s even better than a full GI group, because this whole group just wants to learn and that and they want to be collaborative. And so again, learning from each other. Now, one of the stories was, why do you have that thing dangling at the end of your scope? Well, that’s a different trap. Oh, I never saw saw that before, you know. So learning these little tips and tricks with with each other. The other part is probably a formal course. And again, we’re lucky in Canada that the Canadian Association of Gastroenterology and I think they’ve actually got a partnership with CAGs about this, is there’s a colonoscopy improvement course. So it’s called the SEE course. And they actually have a polypectomy course as well. And this is a really designed, you know, focused, observe endoscopy with a set of skills. I’ve done it myself, again, it’s daunting to have a couple of your colleagues watch you. But at the end of the day, you know, you come up with a slightly different golf swing, it’s sometimes a little bit hard to do it right away. But I have no doubt that, you know, when I did that, I came out as a better endoscopist at the end. And just always remember that, as you said, that the equipment and the skills are changing, the field is not static, you know, what you learn 15 years ago, if you haven’t changed is probably out of date. And that what we’re teaching now is way different than when I first started. So I think really look at these courses, they’re worth the time. And the other, if you don’t have it is to go to some of these endoscopy courses, which we actually do have available within Alberta. I know they do it in some other provinces as well. But really, you know, talk to your colleagues about both things like technique because I think bring it in the open and talking about it, you will learn a lot from your colleagues.

Ameer Farooq  58:29

Thanks once again, Dr. Wong for such a brilliant masterclass on all things endoscopy. Just in closing, if there was anything that you could tell the average general surgeon about colonoscopies that that you’ve noticed from from watching people across the province, that maybe is not that intuitive? What would those things be? You know, besides all the things that we’ve already talked about?

Clarence Wong  58:53

Yeah, it’s a good question. Its so it’s interesting that, you know, again, most people, I think, think about skill and and cecal intubation and things like that. And so in fact, I think it’s actually the opposite is that most endoscopists I see in the province are very astute and very good at reaching the cecum. I think, two of the things that they don’t think about are all the ancillary thing. So so one of the projects that we took over the province is actually harmonizing bowel preps. I hate to say a non-sexy project, no one thinks about it. But when you actually look at post colonoscopy, colon cancer is one of the highest reasons that people got it was that the bowel preps were poor. And so you know, people think about their technical skill. But did you actually look at your bowel preps? Like why did you choose it? Is it evidence based? Is it because your preceptor told you to use it? No. Is it printed in 10 point font that your 73-year-old patient can’t read. So that by itself may improve your pickup rate more than anything else that I can teach you. And so our harmonized bowel preps were actually done again, with a designer looking at the evidence, looking at the balance we had actual patient input into this design, and overall tips and tricks of how to actually drink the preps. And so it was done with the best possible evidence there. So I think number one, is just think about using the right preps. The second part is, is, you know, I think the other biggest change with endoscopy, like anything else is really just just take the time to actually withdraw slowly. And the evidence is really clear about that. And I’ve you know, when the evidence first came out, we had a number of people that were kind of wondering oh well I’m very careful in inserting, but it is really clear, you know, a slow withdrawal will pick up from the cecum will pick up more lesions. So I tell people just take your time, you know, we shouldn’t be racing in and racing out to run to next case. If you’re going to do this, make sure that you withdraw slow. And if your unit doesn’t have it already, use CO2 because your patients are going to be so much more comfortable if you do it that way. So I think if you think about those two things other than just insertion, it’s going to make you a better endoscopist without actually even attending courses started.

Ameer Farooq  1:01:14

You’ve been listening to Cold steel, the official podcast of the Canadian Journal of Surgery. If you’ve liked what you’ve been listening to, please leave us a review on iTunes. We’d love to hear your comments and feedback. So feel free to email us at podcast.cjs@gmail.com or connect with us on Twitter @CanJSurg. Thanks again.