Let's do some little lightning rounds of some thoughts about this and get into some of this issue of margin management and closure. So just a few quick questions. Does anyone have experience with Puristat used for prevention of bleeding? Do you want to make a comment? In terms of the novel agents and preventing delayed bleeding, I don't have any experience, mostly because it's not been something we've been able to do a lot of here. I don't know if you have any experience with delayed bleeding prevention. On these lesions, I just would say that the key is a really good assessment of the vessels and before one goes about closure, I think is really key and important because you don't want to close up over. And it's hard sometimes to get a deeper closure with the clips. So what about, Michael, you show one of your slides with some clips over some scarring. If you have to use hot avulsion, do you close those entire defects or do you actually put the clips over the area that you've just treated with hot avulsion? Yeah, actually we use cold avulsion with adjuvant snare tip soft coagulation, which is called CAST, C-A-S-T, and it's very, very effective for treating any scarred lesion or any recurrence. So what we do is we, when you've got the scarred area, we just remove it with a biopsy forceps. Because it's not attached laterally, you'd be amazed how easily it peels off with a serrated cut biopsy forceps. And then we just paint the area with the snare tip. And because at that point we then have DMI type two, submucosal fibrosis, which means you can't interpret the submucosal plane. You don't know if the muscle has been injured or not. The risk of delayed perforation must be very low, but if you want to make it zero, clip that area up. So we always clip the area up. Just the area, not closing the whole defect. Just that area, just that focal area. That's all you need to do. Because you can see the bland blue map of the submucosal with the intersecting submucosal fibers elsewhere. And you know that that's not injured. So let's, let's look at this. I see what everyone in the panel has to say about when you, when you close and, and how you close. We'll go from me first, which is, I think that's clear that closing right-sided defects bigger than two centimeters works if you have someone who knows how to close right-sided defects bigger than two centimeters. And I think there's some trials out there that have shown that it didn't work much. And we saw one presented, I think yesterday as well. But I think it has a lot to do with technique. So I think the discussion about how you're closing or just closing mucosa, are you getting deep closure? Are you getting a complete closure? That's always the gap in everything endoscopic. So I think it works if you can do it correctly. And that's where we need to keep better training. Yeah, I would echo that. Like clipping isn't clipping, like just because you, yeah. So I think the technique is keep it close and grab, grab as much as you can, as Michael showed. And I think depending on the size, I think the right-sided lesions, you should go for more, but there really are times when the lesion's too big to clip. Right. So. Speaking of the lesions, Michael, that you showed, the issue of surveillance, I know that with your LSTs, you're often going at six months and 12 months, which lesions should you go with six months and then three years? Yeah. So the reason, even with the snare tip, we still do six months because 10 to 20% of people have another advanced lesion and the index lesion so dominates the referral colonoscopy, the primary colonoscopy and the procedure that you do. You spend a lot of time at that lesion. Of course you check the rest of the colon, but it's so easy to miss pathology. So I think they do need an early follow-up. It could be six or 12 months, and then they could go to three years for sure. Provided you're very happy and you have high confidence and you don't need to do routine scar biopsies anymore. That's been shown as well. You can just look, but if you look at a scar and there's any doubt, just take a cold snare and chop everything off. Any take-home messages from the group? What's your biggest current challenge in resection? I think still the really fibrose scarred, because even though you can get it and then you burn it, usually in those cases, your pathology is limited because it's not this nice plane of resection. So I would say that they, and many of those cases are incomplete resections from before that have produced the scar. So they probably make me the most uncomfortable about the patient, particularly if they were high-grade dysplasia just before or such. Doesn't mean we can't, but those I find are the hardest ones. No, I think what you're hearing from all of us is be very good at what you're choosing to do as your techniques and be thoughtful about the technique that you're choosing. And I think you'll get very good outcomes, but as Tanya just said, a quip is not just a quip, a snare is not just a snare, it's how you use it. And so that's what hopefully we're all getting better at as we try to make this universal. You hear we all don't like scarring, so be careful about these too close ink marks and probably these large lesions don't need inking and the partial resections, taking out part of one rather than leave it alone and get it out right the first time. So I want to thank everybody and we'll bring it back maybe next year for some more insights. Thank you.

margin management

closure in medical procedures

Puristat

vessel assessment

avulsion