Manmeet Matharoo: Manmeet Matharoo What I tell my trainees is it's always a delight to see the appendiceal orifice and it's always great to see the Caecum but once you're there don't forget to look behind the ICV and really make sure you take your time. INTRO Welcome to the ESGE podcast, Endoscopy Unplugged. Join us each month to hear the latest from European experts and where we'll discuss relevant clinical topics and provide you with tips and tricks, practical scientific evidence and pearls of wisdom to inform your endoscopy practice. So please subscribe wherever you get your podcasts and join us as we advance GI endoscopy care.

Ian Gralnek: Ian Gralnek Hello everyone and welcome to episode two of ESGE's podcast, Endoscopy Unplugged. My name is Ian Gralnek, past president of the ESGE and I am your host. Today we are talking about tips and tricks in achieving success in colonoscopy. And my guest is Dr. Manmeet Matharoo. Consultant Gastroenterologist and endoscopist at St. Mark's Hospital in London. Welcome Manmeet to the podcast.

Manmeet Matharoo: Manmeet Matharoo Thank you, Ian Gralnek. It's a pleasure to be here. Thanks for invitation.

Ian Gralnek: Ian Gralnek It's great to have you. Before we start Manmeet, I'd really like to take the opportunity to ask you a quick question. How did you decide to pursue a career in GI endoscopy?

Manmeet Matharoo: Manmeet Matharoo Well, like most things in life, I think it was a combination of being in the right place at the right time. I had the very great fortune of doing research with Professor Siwan Thomas-Gibson. She said to me one day, let me teach you how to scope, showed me a colonoscope and I never looked back.

Ian Gralnek: Ian Gralnek Wow, okay, so yes, we all benefit from mentoring. I think it's wonderful and I'm sure she was a fantastic mentor. So let's get into the meat of what we want to talk about. You know, in your opinion, what really makes for a successful colonoscopy?

Manmeet Matharoo: Manmeet Matharoo That's quite a huge question actually. Well, I think it's having the right patient in the room at the right time, the right test, the right endoscopists, having the right team around you and the right kit. And I guess what I mean is have a strategy. So think about why you're doing that colonoscopy for that patient because actually everything flows from there.

Ian Gralnek: Ian Gralnek Okay, I would agree with that. So let's talk about a little bit about the prep. What's your go-to prep? What are you usually using in most patients?

Manmeet Matharoo: Manmeet Matharoo Yes, it's a really important question. So can the patient even take bowel preparation? And sometimes if you have patients, we're all under sort of pressured endoscopy services where we're seeing a lot of patients straight to colonoscopy that may never have met a clinician before. So actually thinking about what are their comorbidities? What is their frailty? What's their mobility? Can they even do the preparation? Are there any contraindications? Do they have renal impairment or cardiac disease or cardiac failure that might mean that they can't tolerate the prep. And we're very lucky at St Marks to have a pre-assessment team which is formed of very skilled endoscopy nurses who are very good at telephone consulting these patients. And then our go-to would be Plen Vu, one of many PEG-based oral bowel cleansing solutions and I think the advantage is that it's relatively low volume and therefore the tolerance would be good and it's cost effective so this is what our unit is currently using but we have other options as well that we might tailor. But what I really feel is separate to the specific prescription of bowel preparation. It's really about getting that patient buy-in, that motivation, understanding of how critical the bowel preparation is to the rest of the procedure. Because if patients don't understand the importance of it, they're very unlikely to be able to deal with quite complex regimes for some patients to follow.

Ian Gralnek: Ian Gralnek So, I mean, do you not have open access? Is everybody screened prior to colonoscopy, either by telephone or in person?

Manmeet Matharoo: Manmeet Matharoo We review all of our referrals, yes. So some will come via the clinic, either they may see a surgical doctor or a physician. They may come from non-gastroenterologists. So yes, we would screen those referrals to make sure the suitability for colonoscopy is there. Primary care physicians’ can refer directly to colonoscopy on an urgent pathway. But even in those scenarios, we'd have to ensure that those patients were suitable. Because sometimes it's not always easy to judge over the phone or on paper as to whether a patient is fit for a colonoscopy, in which cases...

Ian Gralnek: Ian Gralnek I agree.

Manmeet Matharoo: Manmeet Matharoo Sometimes our teams will actually refer them into clinic to have a discussion to say, you could have a colonoscopy, you could do the bowel preparation, but is this really the right thing for you if you're in your mid-80s with comorbidities and discussions about anticoagulation? And then it's a shared decision-making and you feel like you're actually consenting the patient. Because let's not forget, consent for colonoscopy actually starts with the bowel preparation.

Ian Gralnek: Ian Gralnek So we have the indication, the patients, they're prepped and ready to go. What's your sedation practice? And this may be a little bit different in the UK than other places in the world, but I'm interested to hear what sedation practices are you using for colonoscopy?

Manmeet Matharoo: Manmeet Matharoo Patient choice is really key and tailor your sedation according to the patient characteristics as well as the colonoscopy indication. So by that, what I mean is, you know, some patients are regular at colonoscopy, they have surveillance and they take no sedation. They have it without any Entonox or any conscious sedation. There are a group of patients that prefer to do that. Then the next lot will have Entonox, which is essentially inhalational analgesia that they can use. The advantage is being that they are in charge of that and it allows them to walk out of the endoscopy suite unaccompanied. So particularly patients that might be working or have childcare commitments for example often prefer this option. Again, people that are familiar with what a colonoscopy entails, you know, may choose Entonox because actually the goal is to make colonoscopy comfortable, So Entonox is a good option, but I think a good proportion of our patients will end up having conscious sedation, which will be a combination of an opiate based fentanyl drug or Midazolam, so benzodiazepine. And I think my key with this is you've got to work the sweet spot. So you want to ensure that they're comfortable and relaxed and pain free, but not over sedated. The advantages are that when you've got the consciously sedated patient that's just right, they're able to engage with you enough such that you can turn them during the procedure, which is really important. But also you can keep communication going. And actually sometimes when anxious patients come to a colonoscopy suite, the instinct is to just over sedate them. But if you can actually talk to them about what's going on, that in itself is quite useful. So I think particularly when we were discussing this group of patients that are elderly, frail, comorbid, you really cannot underestimate the cardiorespiratory consequences of sedation. So giving really modest amounts, making sure you wait a minute after you give the fentanyl, check their sats and then incrementally increase it with the Midazolam so you have enough. And you know, I have a real interest in patient safety and drug errors are one of the commonest errors that we see in the endoscopy suite. And often they're there without consequence, right? Nothing really happens. It's very rare that you have to reach for the reversal agents. But actually how you can prevent these errors is with this concept of closed loop drug communication. So I cross check my own drugs. I make sure that I and my nurse will check, you know, what is the drug? What is the dose? What is the expiry? So we are both clear exactly what is in the vial. And then if I ask for a drug to be given, then close communication, the nurse will say, okay, 10 milligrams of Buscopan, the heart rate is 80, 10 milligrams given, received. So we are all clear what we have done with the sedation or the drugs that we are giving. Whilst we all know that there are conscious sedation guidelines and the BSG have a really nice guideline on this, the safety of it and the practice of how you build it up, I think is a bit of an art.

Ian Gralnek: Ian Gralnek So you guys are not using propofol at all.

Manmeet Matharoo: Manmeet Matharoo So we are. So if, for example, you have a patient that needs therapy that's prolonged, conscious sedation may not be sufficient. So therefore you may make a plan to access a propofol list. We do do patients underpropofol. We don't have as much access to anaesthetics in the UK, therefore naturally we have less availability and that's just a resource issue. But there are propofol lists that we would select patients for and those would include those that you cannot safely give the conscious sedation to. So you may need support if there's sleep apnoea or cardiac disease or if you're doing prolonged therapy and you expect this is going to be a long procedure. Or indeed the patients that are extremely anxious or traumatised from previous procedures that they actually will not have colonoscopy under conscious sedation and therefore you have to access the propofol list for them.

Ian Gralnek: Ian Gralnek So let me ask you about endoscopy equipment. What really should be the state of the art today in terms of the equipment, the colonoscopes that we're using?

Manmeet Matharoo: Manmeet Matharoo So I think this is really important because we have seen so many advances in endoscope technology and we're very fortunate to have now access to high definition colonoscopes but you have to use the kit with which you have in your unit so what I would say is go to your tech people, see what kit you have, have a play but really you want to have high definition where possible so that you get the best optical diagnosis. So we know that if we are now making more of a push for optical diagnosis, you know, to detect dysplasia, for example, in the IBD surveillance cohort, if you do not have a high definition scope, it is very difficult to detect dysplastic change appropriately to ensure that you are biopsy-ing the correct area or resecting. And if you cannot see, then, you know, we are offering those patients a disservice. So I think it's part of our sort of key performance indicators where we want to keep up our detection rates, but we can only do that with good quality prep, high definition scopes, an adequately cleansed bowel, and adjuncts that you might have such as TXI or NBI. But those adjuncts are only as good as the mucosa that you show it to. So I think you do need to have those.

Manmeet Matharoo: Manmeet Matharoo But I was going to say, taking a step back, know, when you say what kit do you need, it's not a standard thing. And we now have a practice where we do a team briefing in endoscopy and we published on this around COVID time where our practices had to change. So I will sit down with my team at the beginning of my list and run through all of my patients and give an idea as to which scope, which kit, which adjunct I'm likely to be using. So for example, a high def scope may not be suitable for every sort of procedure. I've just done a list this morning and you know, for my surveillance cases, I said, I'll need a high def for this and I'll use an endocuff. But then I had a patient who had previous surgery, pelvic surgery, very narrow pelvis previous fixed sigmoid and I suggested a paediatric scope would probably be better for that patient. So thinking about the kit based upon your patient, their habitus, the indication and what you need to achieve is good.

Ian Gralnek: Ian Gralnek I think you bring up a good point in terms of also adult versus paediatric colonoscope. We have both those in my unit and I'm an advocate that I really think you have to have both of those available because there are certain patients who will benefit from using actually the paediatric sized scope. I'm talking about in adult patients. So I think it's very important point to bring up. Let me go a little bit further and push you, pardon the pun here, about you've actually started the colonoscopy. There are certain patients who have difficult anatomy, whether it's long left-sided colons or they have floppy colons or the sigmoid colon. Can you tell me a little bit about nurse assistance and use of abdominal pressure to facilitate you getting to the cecum every time?

Manmeet Matharoo: Manmeet Matharoo Okay, so I start at the beginning and I always look to see if they've had a previous colonoscopy before and if there are any clues on that report.

Ian Gralnek: Ian Gralnek Great point. It's a great point. Manmeet Matharoo So if for example, and I think that can help you, often there isn't a clue there but it prompts you, me, if I find the sigmoid difficult for whichever reason then I will articulate that in my report and similarly Ian Gralnek I do the same. Yeah.

Manmeet Matharoo: Manmeet Matharoo Exactly, think it helps, sigmoid was best navigating the right lateral, for example. So if somebody has to come back, they have a road map. So have a look. Have there been any procedures before? Are there any clues? What might you set yourself up for, number one Number two, you can sometimes predict it from their body habitus. know, for example, if you know you have maybe, you know, a patient with central obesity, you may predict that this patient might have quite a loopy mid-transverse. I can think I might need position change or pressure here. So being prepared is important. Then the key is, think, using a scope guide, which I would say is a standard part of my practice. And I know that differs across different institutions across Europe. And you asked me specifically about abdominal pressure. So you know, the key with this is I think pressure has to come on and it goes off. So it has to be quite a precise thing. I will ask my assistant, here's where I'd like to put pressure. And given that we're talking about the sigmoid, it's often quite low down in the pelvis. It's not where you might think it might be. So you might be surprised. And then the next point is adjust the couch for your assistant. Because the person that's scoping with you has to be in the right ergonomic set up to apply their pressure appropriately. So I might drop the bed or they might go on a foot stool, for example, so they can actually apply the pressure effectively.

Manmeet Matharoo: Manmeet Matharoo And then patient communication is key here. We've talked about a lot of my patients might be very lightly sedated. And I think it might be quite alarming as a patient if you heard someone say, I'm just going to put pressure on your abdomen. That sounds quite alarming. So I would say we're just going to support your abdomen for this part. That’s nice. So thinking about your language and your non-technical skills and then, you know, putting the pressure on, but giving your nurse feedback. That's really helping keep it on, thank you very much. And then if it's not helping, , you know, take the pressure off, come off, try something else, whether it's position change or stiffener or try another technique. So those would be my initial thoughts with regards to abdominal pressure.

Ian Gralnek: Ian Gralnek So I've used Scope Guide a couple times. We don't have Scope Guide here. And I'll say, well, Dr. Matharoo, I mean Scope Guide is really expensive, and don't I need special scopes for that? And I can't afford that. So what do you say to that?

Manmeet Matharoo: Manmeet Matharoo I would say, you we all have to work within our resources and some people won't have access to scope guide and I respect that. And there are certain patient populations where you might not use it. For example, if they have an ICD or an electromagnetic device. So I think it is important to know how to scope without it.

Ian Gralnek: Ian Gralnek So I guess we're coming to the end of our discussion. You've done the colonoscopy, you've gotten to the caecum. Your withdrawal, do you always do a retroflexion in the right colon routinely?

Manmeet Matharoo: Manmeet Matharoo I think I don't always do it routinely, but I know that this is almost like a key performance indicator. But what I always do in the caecum is I make sure that I wash avidly. I would give Buscopan if it's appropriate, and I would examine the caecum in at least two positions. And the right lateral is a very underrated position for the caecum. The number of times I thought I've got adequate views whilst they're supine and then I flip them onto their right and I just see something tucked around the corner, is quite sobering actually. So I think whatever you do, take your time in the caecum. What I tell my trainees is it's always a delight to see the appendiceal orifice and it's always great to see the Caecum but once you're there don't forget to look behind the ICV and really make sure you take your time. So I guess ways to do that as you said are to retroflex and to make sure that you do it under direct vision and make sure that you are comfortable with the technique of it to ensure you don't miss things. Similarly, would say be really mindful about those high risk areas where you might miss stuff. So, retroflexion is I think a key important part just to make sure you're not missing any anorectal pathology and the flexures. Take time, slow down, change your position and double sweep if you're not sure that you've got everything to just make sure that those high risk areas where we know we miss flat polyps for example that could be relevant that you give your patient the best chance that you can actually see them.

Ian Gralnek: Ian Gralnek Double or triple sweep in those areas, actually, is what I tell my trainees. Yeah, And the other thing, I assume that you photodocument these certain places, right? You photodocument the appendiceal orifice and the caecum. You photodocument the retroflexion in the rectum. I assume you do that, right?

Manmeet Matharoo: Manmeet Matharoo 100%. And you know, I'm in the age of social media, if it's not pictured, it didn't happen. So you've got to take a picture and you've got to have a good quality photo documentation, doing our post colonoscopy colorectal cancer analyses. You we rely on the photographs, you know, if you have really good quality pictures in recto-flexion with a close-up and an NBI and a nicely inflated rectum and then there's a rectal cancer thereafter, you look at that photo and you think this is a really, really good look at the rectum, you know, so I think it has important implications for quality assurance going forward. So yes, photo document in Mm-hmm. Absolutely.

Manmeet Matharoo: Manmeet Matharoo white light in NBI, near focus and Brian Saunders was just saying recently at our frontiers meeting if for example you are you know resecting a polyp really good photo documentation of your resection margin because if you're then dealing with recurrence thereafter you've got a photo documentation of what it looked like at that time so I think you know not just taking pictures of you know normal hepatic flexure but actually think what story are you trying to tell with your pictures.

Ian Gralnek: Ian Gralnek Yeah, and I even have, we have the ability in my department that we can video as well. And if there are certain findings that are important or you're going to use something at a multidisciplinary tumor board type meeting, we'll videotape things and show it because even video is even better than still endoscopy images if you have the equipment to be able to do that. My last my last question for you is what are the absolute necessities? You're going to send the colonoscopy report back with the patient to the referring doctor. What are the key components that really need to be there?

Manmeet Matharoo: Manmeet Matharoo Patient tolerance and how the procedure went. Was it adequate? Was the sedation right? Was the kit right? Your main key findings as well as important negatives. And then what your clinical conclusion is. We are not just technicians, but we have to give a recommendation, a clinical recommendation based upon the indication, the findings as to what happens next. And then finally, accountability. Who's going to check that histology? Who's taking them to the tumour board and who's booking that follow-up? And most importantly actually is what the patient should do if they experience any discomfort or complication post procedure in a nutshell.

Ian Gralnek: Ian Gralnek Do you phone the patients afterwards, 24 hours later, to see how they're doing? Or 48 hours later, do you have that system within your hospital?

Manmeet Matharoo: Manmeet Matharoo Unfortunately, we don't have the resource to do that as standard for every patient, but particularly if there is therapy, yes, we will phone them. Particularly if there is a difficult procedure, we will phone them.

Ian Gralnek: Ian Gralnek We don't do it either. We just don't have the resources to be able to do that but I think we'd be surprised that there are patients that definitely have complaints afterwards and some of them go back to their family doctor with complaints or even to the emergency department that we never hear about. Manmeet, thank you very much for your time today. I very much appreciate it. The ESGE appreciates it as well. But before we say goodbye, we'd like to get to know you a little bit outside the endoscopy suite. Now, you know I'm originally from the United States. I'm a big football and baseball fan, I’ve been a lifelong Minnesota Vikings and Minnesota Twins fan. Do you have a favourite sports team or do you play sports? I know your kids play sports.

Manmeet Matharoo: Manmeet Matharoo you're right. So I have two boys that are avid Chelsea football fans. So by proxy, I support them, but my own sport, I recently got into reformer Pilates, which is phenomenally difficult, but probably good for upper body strength and ergonomics and colonoscopy. And maybe that's another podcast.

Ian Gralnek: Ian Gralnek Ha. Okay, we'll save that for another time. So listen, thank you again, Manmeet. It's been great to have you here. Take care and have an excellent day.

Manmeet Matharoo: Manmeet Matharoo Thank you, you too Ian.

Ian Gralnek: Ian Gralnek Thank you for listening to this episode of Endoscopy Unplugged. If you found this podcast useful, please subscribe wherever you get your podcasts. To find out more about the European Society of Gastrointestinal Endoscopy, for example, to browse our scientific publications, interact with our online learning portal, the ESGE Academy, or to learn about becoming a member of ESGE, visit our website, www.esge.com. And of course, your feedback is always valuable to us. So send us your thoughts via office at esge.com. Thanks for listening and join us next time.