When I made the agenda to go for an hour and 20 minutes going over cases, I didn't realize I would have lost my voice, but we're going to be okay, because it's a lot of just video cases and some of our colleagues have agreed to chime in and tell me what I'm doing wrong in the cases and give their opinions. So feel free to ask questions or talk about how we approach these sort of cases, all right? So again, it's all videos. I have no disclosures, apparently. So this gets to one of these sort of cases that was discussed earlier, which is patients with IBD who are extremely challenging cases. So this lesion, which I didn't know was a polyp, it was referred to me, it actually was a polyp. So marking it here, it's very small, but very fibrotic. So if you guys don't mind me leaning on you, small lesion, so Neil, how would you approach that? It's very small, but very scarred. So I think for this one, it's pretty impressive, actually, that this was seen, I think, first of all. Second of all, I think the temptation is just to want to just try to lift this and be done with it in a few seconds, but I think a couple things we discussed this morning might work really well here. One might be a CAP EMR situation, and depending on how that goes, it's probably even a good size for an FTRD, but that might be a little much of an ordeal at this point for this. It's a good point on FTRD. I mean, my problem with FTRD is I've done more than five, less than 10. And if you're at that number, it's where you actually still feel like you need assistance in setting it up. Yep. 100%. And so that means bringing the patient back. It always takes longer than you think it's going to take anyway. That is any contrary opinions on how you'd approach this? Hi, Brady. You might do circumferential incision? Yeah. If you don't mind using the microphone, too, because the virtual audience wants to hear your thoughts. Yeah. So, no, I think with a small lesion like this, it's always still, I always, whenever I see a fibrotic lesion, I'll still try to inject it just because I've been surprised by how many times something just looks tacked down or I see a tattoo or whatnot, and I say, oh, this is not lifting. And then to my surprise, I inject hard enough that it will pop it up. So I'll give it a shot at starting to inject, and then based on that, how it's lifting or not lifting at all, then I'll make a decision on how to approach it. Something this size, I do agree, CAPEMR is not a bad option. All right. So I tried underwater, thinking that's been my go-to for fibrotic polyps, and you both were smarter than me because it didn't work at all. It was just so flat and fibrotic that it would slip repeatedly. Now, I only tried one snare. You could try maybe a stiffer monofilament snare. Dr. Keswani, where was this polyp located? Ascending. Yeah. So I did do CAP, so it's a good example of that CAP that we're in the technique. So this makes me really nervous, the CAP technique, especially in someone with IBD because, one, the tissue is fibrotic, so the muscle is basically fused to the submucosa, and two is if they do perforate, I've found these are much harder to close than someone with healthy tissue. But I was not – and it's such a pathetic polyp size that, like, surgery would just be stupid, right? You have to do something. It's embarrassing not to get it out. So this is an example of the CAP, which I find a little difficult sometimes because with the snare in there, there's not a lot of space to suction, but I was able to get on the tissue, you suction the CAP, and then you see that close the snare. And I don't have the whole polyp still, but once you get that first piece, everything becomes easier. So you'll see that sort of ugly tissue underneath, and then the second piece is a lot easier because you have a place to grab the tissue. So again, you suction. It's everything you really don't want to do in typical EMR because the reason we don't suction in is we don't want to pull the muscle in. But this is what you're doing here. Again, I've probably done this maybe 10 times. It's rare, but it's something to have in the back of your head as a choice. Any other thoughts, comments, questions? I think these IBD patients are particularly hard to deal with. And I know, so you do ESD as well, right? So do you do a lot more ESD than for these? You know, I'm still at the point now where I'm a little, I don't do the right colon ESD at this point. I think for something like this, if it were somewhere low-hanging fruit, like the stomach or the rectum, I would definitely try. The goal, I think, would be, I really just want to get that out in one piece. But at the end of the day, I would 100% take what happened with you. I was happy, but it's really inelegant. But that's what these cases are for. Not everything looks amazing. It worked fine, but it's really kind of low rent, what I did. Yes? Do you clip those? So I mean, you know the data, and we'll get to it tomorrow, but the data would be polyps greater than two centimeters in the right colon is where we've only seen benefit. And that's when experts are clipping. So if it's an easy place to clip, I'll clip it anyway and ignore the data. But if it's a hard place to clip, or the data says you don't need to clip it, I won't clip it. So I think with some of these newer clips, it's a lot easier to clip some of these very fibroids. You can get more normal tissue. This is obviously easy to clip, but some of these IBD patients, it just slips, the old clips. All right, here's another example. It is a run of appendicitis orifice polyps. This is another good example for you as you're sort of growing your resection practice of the things people will send you, and they always send you with caveats of why they shouldn't feel bad about themselves. And usually it's like, I helped you out. I started the procedure, which is like my favorite. I got it going. You can just finish it. I find these very humbling polyps because you never can tell how big they are until you start. And you see that sort of mucus cap there. And then I think I can show you in a second what they took off right there. See that little scar? That's where they started to take it. But these are fascinating polyps. So if you actually get your cap on, put it underwater, you can actually get deeper in and actually see sort of the extent of the polyp. And the cap is really helpful to sort of open up into the orifice itself. So my first approach for any appendicitis orifice polyp is how deep in is it going? Is it going into the orifice or is it going right next to it? Because that really changes your approach here. So I think you can see here there actually is a border, although small, with the orifice. If it's into the orifice, I know we saw a couple of those videos where they suction into the cap basically and cutting out the appendix. But that's a different technique. Obviously, FTRD would be an option into the orifice as well. So in the audience, do you have any sort of thoughts on how you'd approach this lesion? You can sort of see the extent of it now, right? All around. Anyone take these lesions out currently in their practice? Because then you can come up on stage and do the rest of my voice. All right. Anand, how would you deal with this? So in the view that you're looking at right now, that you had there underwater, you could see the edges pretty nicely. I might take that big chunk off right there underwater. If it seems to be floating in, it seems to be okay. That scarred area seems like it's going to be a little bit more difficult. But I think you can get the bulk of this underwater. The other option, and this is somewhat risky just because it can make things worse, is trying to inject underneath and see if you can pop it out of the appendiceal orifice now that you saw the edges. Sometimes the injection could also make it invaginate in as well. But in that view, I think I would just try it. I mean, you said everything exactly how I feel, which is in general the injection. Because the appendix doesn't come out when you inject it. So the tissue usually goes into the appendix. So I tend to avoid injection at the appendiceal orifice until I get to more of the laterally spreading component. And so I went with your approach, which was underwater, sort of resection for this. You can see the key here, and I sort of don't want to gloss over the key part, is if you're going to do that, you've got to get the snare into the normal, the tip of the snare into the normal part in that orifice. You have to just accept that you're going into the orifice. And I don't do ESD, so I lose options. So I have to do everything else. So you can see it's actually, this is where underwater works really well. We're just basically grabbing pieces of tissue at a time, and you can make your way sort of marching around. A little bit of the cap suction underwater that you saw before. And you just want to march your way circumferentially around a polyp. So you can see getting closer to what the orifice would be over there. And really trying to get my snare tip embedded into that. Slowly open it so the technique is a slow open snare pull your scope back and try to really get that piece by piece. So, Neil, would you have gone FTRD for this? Not after watching you do it like this. I think a lot of people would just because of kind of the newness of it. But there's actually a really, for those of you who are on Twitter, a really good debate going on right now about these types of polyps and FTRD and whether or not to send to surgery and things for a little bit more aggressive lesions. But I think for this one, what you're doing is really fantastic. I think I would have tried something similar. What did Elon Musk say? He said, get off Twitter or pay $20. And so that's the essentially resected everything into the orifice. And this person I've followed for a couple of years, that's the six months of what it looks like. And that's the orifice that's left over. To me... I just want to add a point on what Sunil talked about. This would have been a very difficult case for FTR, even if you wanted to. I think you did a great job. Because if you look, the area that was scarred now is eccentric, right? So you have all this normal tissue that's going into the appendiceal orifice. So that's tissue you're going to have to try to EFTR. Yet the scar portion is on the periphery. So it's going to be very hard for you to pull both the normal tissue and that scar tissue into the cap. And if you try to aim at the scar tissue, you're probably going to miss the normal tissue invaginating into the appendiceal orifice. So I think the way you did it was great, which is removing the normal tissue. You probably removed all that normal tissue that's invaginating into the appendiceal orifice. And then you probably took out that scar last. Because you already had a ledge basically isolated, almost like a little island, and then take care of that. And we'll talk more tomorrow about the idea of why we do the circumferential incision, which I haven't adopted much of yet. But it's the right thing to do. It's because once you have a place to anchor your snare, it slips less. So once you've gotten this tissue here, removing the lateral edges becomes a lot easier. But yeah, so the other thing to think about is whether the patient has an appendix or not. This has some risk of appendicitis, but it's not nearly the risk of appendicitis as FTRD. So for these patients, I think she had an appendix. I put her on antibiotics and nothing happened. But FTRD, the risk of appendicitis, I don't know if any of you have the numbers just off of your head. 17. What's the number? 17. 17. Yeah. It's 1 in 5 almost. Or math. Math. What was the pathology on this in the last case? Serrated. Even the last one too? This is adenoma. The IBD one was adenoma. Which is weird, because I would think it's nothing. No dysplasia? No. Okay. I mean, adenoma is dysplasia. No, no, no. I mean high-grade dysplasia. No, no high-grade dysplasia, yeah. Just a random shout-out, since I'm a person who cares about quality. Make sure you always look for polyps. You guys are all very talented in the room. Does anyone see the polyp in this video? I paused it for a second, this still image. All right. I mean, this is not the most subtle polyp we've seen, but I'm just showing you examples. And that will help you get more resections, because you'll find them yourself. It's starting to come into view. And then, these tend to be fun lesions, because they're easy to find. It's a pretty big lesion, that is hard-ish to see in the beginning, hard-ish. And they can be just sort of ones you can work on, whether you want to do cold snare. This is also a good example of how much bigger the lesions become when you inject them. It wasn't a big lesion, but it became a bigger lesion once we injected it. So obviously, get good into the looking for polyps part of the thing. I assume I did a good job. See? Easy to clip, clip closed. You don't believe in using blue light for flat polyp detection? I believe in it for adenoma detection. I don't know of any good data that helps us find serrated polyps. This was serrated polyp. Right. If you had seen this in a blue light, you think you would have picked it up easier? I don't think so. What do you guys think? With NBI or FICE, do you think it helps for serrated polyps? I've looked at the data. I'm not seeing good data on it. I don't think. I mean, it's hard to. Will you just do an exam with NBI just for that one? I mean, when you see something like that, I think most of us would just turn on the NBI and look at it and say, oh, let me look at it a little closer in a different modality, you know? But I think it's easy enough to do to just take a quick look. Sometimes the margins can be difficult to discern with these serrated polyps. NBI may help you, but a lot of times by the time you lift, then you're going to get very clear margin demarcation. So that's the NBI data actually is really good to find. It's one of these things that the data is really good, but no one does it. With the new high definition scopes that are the brighter series, like the new Olympus scopes, in randomized trials, NBI finds more adenomas than not. But I don't know of anyone in America that routinely does detection of polyps in NBI. I mean, there is a whole new classification, NICE. And then the biggest person in colon, this thing uses NBI as he reaches the cecum, and then he withdraws using NBI, goes back and again doing it. Is that Doug? Yes. Yeah. So I mean, the data would support, and Doug's done one of the trials, the data would support that. There's very few people who do it. I don't know why. Well, it's helped me, so I can tell you that. It's the right thing to do if you look at the data, saying it helps you find adenomas more. All right. This is a duodenal polyp. We're not just a colon course. So this was previously biopsied as a carcinoid. It actually had two carcinoids in the ball, both were small. So I tried to inject it, and that central depression was not there on the pictures before. That seemed to be where they biopsied it. I have a hate relationship with duodenal carcinoids. I find them, they lift poorly because they're, by definition, subepithelial. So it's hard sometimes. Sometimes I feel like I'm just pushing them in. In this case, I was blaming it more on the prior biopsy, but it could just be the carcinoids in general. So maybe we sort of just take a minute here. You see the scar. Actually, you can see the scar from the biopsy right there. So it's a pretty small lesion. So many of you would see this in practice. Any sort of ideas on how you would approach this lesion? I tried to inject it. Inject. Yeah, so band ligation is interesting. Do any of you all do band ligation for these, for the duodenal? I mean, I do. I mean, that's how I generally did them in my training, and I still kind of do them. I mean, the first one I did as an attending, I had a little bit of perforation in this situation. A little bit of a perforation. But it was because I was—so, you know, obviously, the wall in the duodenum is super thin. You have to be super careful. And then it was really just trying to close it with the clip just kind of going right through the wall, and it was really frustrating. But since then, I've always been super cautious about this, always having an over-the-scope clip in the room or something like that if I need to. But I think this is an example where an FTRD could be a good situation, a good thing to do. And I hear people describe that, again, it's super challenging, and a lot of times you don't get a good R0 resection with ESD for the carcinoids. So it's not an easy situation. I don't know. Dennis, what do you think? I've done a lot of band—especially for the smaller ones, I've tended—you know, because band EMR is relatively easy to do. The one negative about that is oftentimes I get the positive margin with the band EMR. It's a big negative. And then you're dealing with the scar and going back and trying to resect where the scar was. So like Sunil said, EFTR is an option here. This one is right past the pylorus, right? So it's going to be a little bit challenging because the EFTR, you've got to remember, it protrudes a certain distance from your scope. And the most difficult part for the upper EFTR is right past the bulk because your scope is not going to be stable enough to get—or at least it's very challenging, especially this one is more kind of like a 9 o'clock position. So I do ESD, so sometimes what I do is I'll use a clutch cutter knife, which is a scissor-type knife. So it's a little bit safer. So I'll lift, and you see that normal mucosal part that I lifted? I'll cut that side to start exposing the submucosa to give me a sense of where that carcinoid extends, and then I'll try to put the snare, almost anchor, almost like a hybrid. Hybrid approach. Yep. Yeah, I've actually never done band ligation duodenum because I've always been taught that it's high-risk for perforation. So it's interesting, you—you, Sunil, you've used it a lot, Dennis, you've used it a little bit, and only one complication from a quip closure. Yeah, yeah, it's such a protruding—you're trying to close it protruding. Right. I guess it's a good point, yes. Usually quips don't do that. Yeah, because it's—maybe it's just the teaching that I've gotten, which is, that's not how we—I don't know why, because the esophagus seems pretty thin-walled as well, but, you know. Also, I mean, there's—I think there is an appreciable debate about cutting above or below the band, you know, in these situations also. So, you know, you want the margin, but at the same time, you want to be safe about it, but—so now, and every time I do them, I usually don't have the cojones to cut below the band on these, so I just hope for the best. And theoretically, that band above and below should be lateral margin, if we extend what the esophagus is. It's not the deep margin, although, I don't know if anyone actually knows that. We all say that, but it seems hard to study. All right, so here's what I did, which is not very impressive, but worked well. You're never going to see a better advertisement for underwater EMR than this. It like ridiculously worked well. And a negative deep margin, which is surprising too. Raj, do you think your injection actually helped with that then? Because I think that's, you're seeing a nice little stalk, but a little bit of a normal tissue underneath, which I think was the result of your injection. Do you think it helped or hurt? That's what I never know. It worked. I'm just looking at the questions from the virtual audience too. I don't have a good answer for you, because it didn't seem like the injection was helping me after I injected. It maybe would have just come out with a snare anyway, but it really did float. This word floating that they like to use in underwater literature, it was ridiculous. One question is about what snares we, I use only Olympus Snare Master snares, so 10 and 20 millimeter snares. That's my preferred snare. On what snare are you using? The Snare Master, with the caveat that it's good to know what the differences are in terms of the 10 millimeter snare is a lot less stiff than the 20 millimeter snare, which they have designed as a braided snare. The one in between 15, that will give you the in-between size, and that one is also not very stiff, not as stiff as the 20. The braided idea is it slips off the tissue less, so a little different than the snares you saw, which was the monofilament snare, which is not the braided design, but very stiff. Dennis, what snare do you use typically for your EMR? I generally use a monofilament snare. That's just ConMed, and who else? I don't know the other ... ConMed. I don't know if there's any ... Okay, so you use the Beamer, right? They call it Beamer? Yeah. Are you a Beamer guy, Sunil? I use the Captivator snares. Okay. All right, and I think we ... I think we have a few questions about keeping the colon still underwater, and Jason's theory was that the colon shouldn't be still underwater, that that motility of the colon is helpful. Obviously, you can give glucagon, but usually if you give that water, you don't find this ridiculous motility where the water is just flowing away, so not as much of an issue, but if you're finding your underwater EMR is not working, you could turn the patient make the water dependent on the lesion, right? Here's another polyp. So these are tough, too. We'll do things besides underwater soon, don't worry. Dennis can already see where this is going. This is going to be underwater, isn't it? If I don't do ESD, there's really not a lot of choices at this point. What do you do? Are you doing circumferential ESD at the ICV? Have you done it yet? I mean, these are, again, the same ones that are tough to manage. So I tried to mark it, although I think sometimes I'm very impatient on my markings, and then I'm really disappointed I marked it at all, because they don't tell me anything. But the same concept that we talked about for the appendix. Your goal is to get your snare into the ilium. Instead of the orifice, you're getting into the ilium, opening your snare up, and then trying to resect piece by piece, sort of making your way all the way around. This patient had more of a California prep than an Ohio prep. Chicago gets both preps, so it depends. It's a very basic thing, but when you're doing these sort of circumferential or just long piecemeal EMR, your snare needs to be within the resection bed of the prior, or a prior resection. If you leave the bridges, you're going to be in a lot of trouble. So basically, you can still make your way around and around, as long as your snare is embedded on the lateral tissue. And you want to take normal. I find it very hard, and I'm actually curious from anyone in the audience, I find it very hard with these polyps at the ICV to know whether it's ilium or adenoma at some point. So I've seen some tips on that, but I'm curious if you all get a good... So this is the final resection. That's into the ilium. It looks like I did an EST. I should start at the beginning and then just say, EST was performed, and then come back. And it looks good. So do you have any sort of similar issues in the audience? This issue of duodenum happens, too, where I'm confused a little bit. Is it adenoma? Is it just normal vitili? Any tips or tricks? Just no? Sunil has an idea. No, I just... I think this is... It's very challenging, 100%, but this is where I think NBI sometimes can be a little helpful to tell if you look very closely. When you inject sometimes as well, that helps with this sort of situation. But I think this would have been super challenging if you had injected, and I think you did it probably in a tenth of the time someone would have done an EST. It seems like a really good way to do this. Were you worried at all, or did it cross your mind about the possible stenosis here at the IC valve? Not until... Who said it this morning? Ottman? Yeah, Mohammed said it this morning. But no, I mean, I think I've maybe done a dozen ICV lesions, maybe 15, but I see K-series of EST at the ICV, I think Stavros has published like three-digit numbers of IESD at the ICV. I don't know where those patients come from. They're probably living with the appendicitis orifice patients in a commune somewhere. I have not been... And when I've gone back, they've not had issues. Have you... Any of you have seen this before? Stenosis? Yeah. It makes sense that it would happen. This is a really nice... You know, ICVs are really tough areas because they don't inject well, but they're very forgiving because there's so much fat underneath there that it takes a little longer to get the snare through, but it's not generally something that you worry about perforation. I think going back to what is normal, what's abnormal, how much to resect goes back to the whole, like, how easy it is to clip. So if it's easy to resect that extra piece, you just say it's polyp, but if it's not, you say, no, that's probably the normal border. Just keep going into the jejunum. And, Roger, what you said about your markings there, I think they were actually helpful. You have to do a good job. Or at the very least, you know, you were able to get a good look underwater, mark, and then afterwards you don't see marks. And so even if it wasn't perfect in terms of marking, at least you know that you've gotten what you thought was the border. Yeah, I guess I should say better. If you're going to mark, which is actually probably a good habit, or I'm sort of really selling Dennis's talk tomorrow, or doing a circumferential incision as a marking, maybe not here, but in general, do a good job on the marking. If you do a bad job and you have one marking that's far away and one's close, it really just makes you confused later. So sort of going on the topic earlier, these sort of fibrose polyps here, so this is someone who I removed all that stuff to the left after it had been incompletely resected. And then I see this stuff right here, which would look a little bit like a quip artifact maybe if there had been quips there before. So it's just like sort of scarred folds that are right there. So I heard earlier, I think Dennis, you're a Hadavulgen guy, Hadavulgen for your fibrotic polyps? Yeah. At least some of that data that Michael Burke has published, hot avulsion versus cold avulsion, and then APC seems to be comparable. So you could argue in these lesions, you could just basically use the colbiopsy forceps, bite it off, and treat it with the snare tip and whatnot versus Hadavulgen, but yeah. I believe everyone does that, though. So if they do cold avulsion, they ablate afterwards, right? So cold avulsion, I think everyone in the audience knows, but we didn't really talk much about it. That's the idea that I usually use a large capacity forceps, sometimes a jumbo, basically like literally the most basic way of just... It's called cold avulsion. It's basically just biopsy forceps to make us feel better, and then we ablate that tissue bed. I like both methods. Hadavulgen works weirdly well if you haven't used it ever. We saw some examples of it, I'll show you this one too, but it really does get the tissue out. Anand, what are you using for your fibrotic polyps? So we're not varying hot lapse forceps anymore, and so I was actually curious of what are the alternatives. So you're doing cold avulsion and APCing. Can you use the larger coag graspers or anything as the hot avulsion device, or do you have to get hot biopsy forceps for that? You've done that? I've not done that. Yeah. I've not done that. I'm curious. Oh no, Dennis seems like he's done that. Yeah. So I mean, the coag grasper doesn't have to spike, right? So it's unlike the hot biopsy forceps. So you can just use it. I do it all the time to, instead of using multiple devices, I'll just put on ESD settings and use the coag grasper. But I'll still use the smaller one. And everyone has different, so I'll switch the hot biopsy forceps. I find it grabs the tissue a little bit better, but maybe that's just bias. The settings that I use and that were originally published for the hot avulsion would be like your standard ERCV sphincterotomy settings. So if you don't have the Erb-E-Rep come in, if you just plug it in and say you're doing a sphincterotomy basically, you can do that. This is what it looks like. I mean, this is not going to impress you. It's just interesting to see how it works. So you basically grab the tissue again, tent away, and I treat it as if it's a mini, mini snare. It just sort of pulls out these tiny, the world's smallest snare of that tissue right there. And then you just keep marching your way along. I've had maybe just one, but one pretty big bleed I think was from this technique. I mean, it is a decent amount of cautery and you sort of are working your way through. But you end up, if you do it marching along and it gets super inelegant, but it starts to look like you did something better. But you have to sort of get all the tissue out then. So really, really fibrotic polyp, I'll do this. Well, they did it last week, first time in a long time, because I thought it was just a very fibrous, someone incompletely resected a polyp. I thought it was all fibrosis and it was submucosal cancer. Not all fibrosis is someone hacking away at a polyp. It's sometimes something worse. And I would not treat, hot avulsion is not a treatment for submucosal invasive cancer. But that's kind of how it looks when you're done. It looks like you've done a polypectomy. I think one of the takeaways from your technique there is how you really are tenting away from the underlying muscle and applying a very high current density. And that's really the safe way to do this. It's easy-ish to do. It's easy to do. It's just that you have to watch out for the risks of bleeding and perforation. Are you sending those pieces to the pathology? I do send the piece to the pathology, but they're basically just going to be char. That is another negative of this. It's competitive, right? Right. It's at least something. And finding it is the worst of choices. So your goal is, it's a good point that's sort of been emphasized. We used to just APC, like the non-lifting portion. And like with all the other things you don't want in your life, you bury it away. It haunts you later. It'll haunt you in a year when it's like buried adenoma. So something else important to do is just get it out. All right. Something, a change of pace. So obviously you know what you're going to do for this polyp. So big pedunculated polyp in the actually GJ anastomosis. And I love endoloops. Love them. I have a love-love relationship with these. I think it's fun and it works. The polyloop. I love them. So here you can see, this case I wasn't expecting to see this lesion. And I always have this sort of uncomfortableness about doing something that's going to make the patient bleed a lot if they're not consented for it. So I did this sort of two-stage technique. So the key of an endoloop, and does anyone in the audience use them? It's just me who loves them. All right. I've got one partner or so. Oh, okay. Use them but not love them. Yes. You need someone who's competent because there's an invariably mistakes that will happen. But they come in packs of like three, I think, or something like that. So I'll just waste one. That sounds like, how poor is your hospital right now? Exactly. What the hell? All right. So the key is to get it at the base right there. So what I do, which is, I wouldn't say some sort of amazing modification, is I'll get it at the base and I'll squeeze and I'll wait like 15 seconds or so, and then I'll squeeze a little harder and wait some more time and squeeze harder. Because if you just squeeze and put it on, within 10 seconds, the pulp will become ischemic enough that the loop will just be hanging there. So I try to extrangulate the stalk and then get the loop on even tighter. So that's why I hold it for longer. Or sometimes, because I love them so much, I'll put two on, I'll put the second one on right after it. Love them. So you can see here, I'm continually getting it tighter and tighter. You're not going to cut through. Everyone else says you can cut through the stalk. It'd be amazing if I cut through the stalk. So the key is, for those who don't use these, you're closing the loop. The way it's manufactured, you're closing the loop irreversibly, and then at the very end, you let go of this tightened lasso. So you're about to see us let go. You can see this clip is sort of coming forward, tightening up against the tissue, and closing that loop tight. And so when you're ready to release, I love them so much, I make them last forever, actually. There you go. But now you can see the whole pulp is ischemic, right? It's a pretty big, productive pulp. There's another one to the right of it. Ignore that one. I have a question about that. Would you have injected that kind of pulp a little bit? Would it be a little bit smaller? Would you need to go down more? I try it every now and then. It doesn't work for me as well as for other people, but... It works for you? It makes it a little bit small. I feel like... You do the stalk, or you do the head? I do both. And I feel like it shrinks it down a little bit, so I have a little bit more room to work. It's usually because you're in the same way. And so I'll do it on the way in, and then when I'm on the way out, it's kind of... It seems a little bit too small. If you worry about heavy and the stalk, it may get clumpy and... Yeah, I mean... I just... I haven't got, what I will do sometimes is put it on and then wait like 20 minutes on the way in, put a loop on, and the same thing happens. But if you can't get the loop on, then obviously you need to do something. And then here's the, I didn't reuse the same one. Actually, you can't do that if it's already on. So this is the next one. I put over it when the stock has shrunk more, just to see what would happen. It goes on top of the other loop, like right above it. Anyway, so in this patient, I think he was actually on, let me make it up, he was on Plavix at the time, so I didn't do anything. I just put these loops on, and they came back. Let's see if I can, oh. Here's the second one, right above the other one, best friends, both loops hanging out together. And then I just let them live together for a few days, do their job, and then the loops always fall off once the polyp gets shrunk, but that's what it looked like afterwards. And then I took that out. But guess what I did before I took it out, just because I love it so much. For no reason. No, I think I should get a new one over here. Both, probably. What about band ligation? How would you do that? You just go up, wear it towards below, or suck that. You can do that? And band it. I do it for gastric polyps that are all hyperplastic, and it's very efficient, you know? So you can, do you do it over the stock? You can kind of band it, it's like a pajama, you can band the stock. Lyle's very concerned. Oh, sorry. Oh, she wants her to use it. I don't know that I officially want to put this on the recording. Exactly. Yeah, you can use bands. Good. I'm actually making sure I understand. Yeah. You can get your band ligation device onto the stock. Yeah. Suction the stock in. Yeah. So it almost like, Yeah, folds it. Inverts both sides. And that takes about a 10th of the endoloop situation. Easy in the stomach. Obviously, if you're in the colon, you'd have to go. Yeah, no, no, no. Well, in the colon, you would take out, I'm talking like inflammatory polyps where, or you're worried about someone bleeding. Just a thought. I like the idea. For your next video. I want to read this. Yes. So this thing with the endoloop for pain, will that affect the polyps? Yes. So you have to really know it's not, I mean, I've screwed up. I like endoloop so much, I've used them on things I shouldn't have. I, something looked like this. I'd put the endoloop on, but then I did a biopsy of the surface and it was at the GE Junction. And it's just like this. And biopsy came as Barrett's high-grade dysplasia, but it was like a big, giant, penunculated polyp. So I brought the patient back very quickly the next day and took it. Inflammatory, hyperplastic, anemia. I don't know. Banding is a way to go with these hyperplastic inflammatory polyps. You can use like a couple kits worth if your device happens. See, I can tell. When I'm lying, I start coughing. All right, well, anyway, the polyp came out. I was a hero to everyone except for this room. I get these maybe once a year, which are these sigmoid polyps, which are draped over a fold. And I have no idea how big the polyp is. So you can see, it's like sitting there. A cap kind of helps, but it doesn't help because it's like, it's really dipping over. So I never know what to do. So Jen, what do I do? Would you try to retroflex? So retroflex with what kind of scope? The ultra-thin, I mean, the one, the newer ones. Yeah, there's a nice new one. There's an Olympus, really thin one. That's the size of a upper scope that retroflexes. Like my kindred soul, this guy right here, where it must be related. That's what I did. I did upper scope and retroflex. I find it's really helpful for the sigmoid polyps. Because you get to start to move it around. In the end, I did a very below average resection. I just went back to forward view and I treated it like a Paris 1 SP because I could sort of see that the base was small. I mean, I wasn't sure about that in forward view. So obviously we all retroflex in the right colon, but for sigmoid, it's pretty easy to retroflex in sigmoid with an upper scope. And you can see how small the base is. So, something useful to try. All right. Here's a polyp near the ICV. It's just another example of why tattoo can be challenging. Just a question, why would anyone tattoo? That's my question. You tell me. I can get you a soap box right now. Turn on your microphone and tell the world. Thank you. So, this happens not infrequently. And there's really no role for tattooing at the cecum or the ileocecal valve for resection. Just a description of the location is adequate. And so this, I think is a knowledge deficit in practice. Where's the right place to tattoo for, if ever, in rectal? Because I think there's no good place, but Dennis, you're an ESD guy. Rectal lesions, tattoo? I mean, Aziz was just complaining to me on text. Why is everyone tattooing rectal lesions? Yeah, I don't think there's a role for either rectum, cecum, IC valve, obvious polyps. So, if you can see the polyp, there's really no need to tattoo it. How would you all approach this lesion? And there's tattoo inside the polyp, like best friends, like my two loops. So, I think it's important to look at it in forward view and retro. That's what you're seeing here. That's the appendix. There's no polyp there for once. And then, trying to see the bulk of the lesion in retroflexion. Besides tattooing, is biopsying the lesion. I mean, obviously, this, you could biopsy bulky parts of it and not cause trouble, but it's kind of amazing how a little bit of manipulation with the polyp really kind of can screw up what could have been a really easy resection. Now, would you cold stare this? You're such a fan. This is super bulky. So, I think it's important to look at the polyp and then, I guess I would probably inject it first and see what it does. Because, like I said, they can look super bulky, although that does look super bulky. But, you know, a lot of times, it really sort of spreads out in it. You could start with the edges and do them cold and then decide, if you get into it, that it's too much. I don't know. Like a hybrid. You can do a hybrid cold stare and hot. You're not taking in one piece, so you don't really have to necessarily make that decision. Oh, but wait, no, I'm kidding. Oh, okay. So, Neil, how would you manage this lesion? I mean, this screams underwater to me. This is, I've had success in this situation with these super tattooed. I mean, I hear what Jason said earlier, but I think this is a great lesion to do underwater. Probably would have been the right idea. I think I did, like, I think I did inject it because it's hard to me to do underwater in retroflexion. And I can only see the bulk of the polyp in retroflexion. So I haven't had amazing success with retroflex underwater, Yamaha. Have any of you done that well? I think retroflexion is hard. I mean, you know, forward, back, back is hard for me. I think it's challenging for me. I mean, I've always seen your videos, actually. I loved retroflex. Yeah. I know loops of retroflexion. Can I do them together? Can I do them together? I gotta go. So I injected in retroflex view and forward view, but I think Sunil is right. This ideally, if I'd start with underwater, it might be easier, but this is in the cecum, sort of retroflexed to remove the polyp. So you need a really good scope for that sort of ability to see behind the ICV. This is not like great work. It's very hard to get the snare well-positioned and then your scope might slip and you lose everything. But essentially, just piecemeal resection. If I recall, this looked pretty bad when I was done with it. Let's see. I do PEDs with CAP for everything, which limits your suction ability, but it really makes the maneuverability. So this is where you start. You can't suction with the device down the channel, right, for a pediatric scope. So if you're trying to suction the lumen while you have a device down, that's the thing about, I mean, I don't use pediatric scopes very often for that reason. I agree, it's a deficiency. You get a little bit of suction ability. Depends on what snare size you're using too, but it's definitely a big limitation. But I find it so hard to otherwise get the view of these polyps. I think I got the polyp out. I don't know, that's just the tattoo scar and fibrosis. Ignore that. Oh yeah, I did get it out. So those are all pieces that have to be collected. But I think it's, to me, it's the sort of point of this course is if you go in saying, I only do one thing, unless it's endo loop, you're just lying. You have to have a variety of tools that you're using. So that's just another example of rectal reflection. All right, gastric carcinoids. So right there. Who can tell us the types of gastric carcinoids? It's like a board's question. Hardest thing to remember for me. Anyone remember? Type one, two, three? Oh gosh, there's a four. So this is associated with, this person had pernicious anemia. Type one, which is hypergastroanemia, pernicious anemia. I think type two is hypergastroanemia, but not from pernicious, well, pernicious anemia. Why'd they get it again? Thank you. And type three are the worst, sporadic. I hate memorizing things that have no basis. But people have said type one's the best, like number one's the best, type three's the worst. So how would you approach this? Let's go with Ashley. Well, I think, try to suppose that you're an EMT. Or EST, I mean, that's a pretty decent size. Yeah. I mean, EST, I think is probably the, is that probably the best approach, Dennis? I mean, I'm not gonna do it. So obviously, but is it the best approach? That's probably the best. Might just turn in a microphone for the. Yeah, I probably would. It's a decent sized lesion. You can get the wider margins with ESD to make sure you've got. Yeah, I mean, it's one of those things that, well, I didn't. So this is the FTRD device. And I don't think this is an unreasonable thing to do. It's what it's made for. Lesion's less than two centimeters. But I've had sort of mixed reviews of my time with these devices. So I'll just show you how we approached it. And you're gonna do this in the hands-on in about 20 minutes. I'm sorry, two hours when you do your hands-on. So you'll see the grasping forceps right here. You need to be able to grab the tissue and then slowly work your way into the cap. And I'm grabbing, it gets bloody and it's confusing. And then you're like, where were my markings? I should have done a better job. But it took a while to get the, to really make me feel like I got the lesion in. I think I've already deployed it. Right there's the, so just to emphasize what Leith talked about, here's your ring. I'm pulling my forceps back. I'm gonna deploy the clip. It's possible nothing's in there. I agree, Ashley. It's a raw gauge that just seems like it's gonna be tough. Yeah, I mean, I think you can bring it in. It's just that you have to really work it like you work a varix or something like that. I'm not sure it works well. Raj, are you typically grabbing the lesion itself? Yes. The center of the, because what I found is that's, I mean, yours got a little bit bloody. Mine sometimes rips and like, and now I've torn. So sometimes I try to, I found it helpful to grab just on the edges of my marking and if it's a normal tissue, it'll bring the whole thing in along with the edge tissue. But that's only if it's, because a lot of, again, these are subepithelial and I have a better luck with these, but sometimes they're scarred down adenomas, like in the colon that I've tried this with, with FDRD. I'm always just ripping the tissue. And, but I think the point was made in the talk earlier and you made a similar point, go slow. And I think partly was maybe just impatience of just waiting and wait. Right, you basically have to just like negotiate with the, this is what it looks like here. This is weird. That's how you always want it to sound, doing a case. This is weird. Yeah, you have to really negotiate the polyp into your cap rather than the cap under the polyp. It's like you're doing a dance. And so the big worry is the quip's not on. So thankfully the quip was on. I've had one I did with padlock without the FDRD system that had pretty bad post-palpectomy syndrome, no perforation. And then this patient had pain, but no anything, no white count fever, but bled, like not delayed, but immediate bleeding, which is interesting. Because as we talked, you wouldn't think that the treatment for, you know, bad vessels is over the scope quip, it wouldn't bleed. Just kept bleeding, I kept staring at it. Bleeding. Hopefully not, no, yeah. I just kept staring at it, but then I just co-aggressed it. But I think Dennis is right that it's much more elegant and controlled when you do ESD. But there's like, you know, 10 Dennis and Sunil's in the world. Okay, like a couple hundred Dennis and Sunil's in the country, and there's like a million of me. So like anyone can do this, you know, gastric ESD for a carcinoid is still tough. All right, so this is, you're gonna teach us how to do hybrid ESD tomorrow, so I'm not gonna show you that video. I think, in the interest of your sanity, let's take a 10 minute break, and then come back for a couple lectures. That sound good? I'll leave the bonus case running for those of you who wanna watch it. All right, thanks. Thank you.

polyps

lesions

intestines

stomach

endoloops

electrosurgical dissection

underwater EMR

hybrid ESD

gastric carcinoids

Olympus Snare Master snares