The next case is actually a continuation of the last large bulky polyp. Click that put that slide up please. It's part two. So, with the next, the next part of this session is going to be tidying up the, the after we've done, we've chosen our resection, we've done our resection, which whichever evidence based way, hopefully, we're now we're going to deal with today is about dealing with the, the resection site. So we're going to talk about controlling bleeding acute and prevention, the circumference and closure, and we'll have some discussion in a group about closure particularly the end so just going to move ahead. See the slides will move forward. There we go. Excellent. This is a little before the last picture so we had a little bit of this down there on the video. Okay, so we're, we're, we're, we're expecting the base very carefully and using underwater as well we see some acute bleeding there. And, you know, I'm going to go and use a hot biopsy forceps closed with some soft coagulation. So what what accessories will you use when you have acute bleeding, and what settings specifically will you use. Yeah. So we use a snare tip that works beautifully. You can put you know fairly firm pressure with the tip of the snare precisely on the bleeding point. And then you just use at what's effect for soft coagulation and it, it, it'll stop the bleeding sort of 90% of the time. Yeah, yeah, but soft coagulation I think is the key point. So, it's a very sizzles at a very high, high power power setting and just like searing a steak, just on this one and get it right on the surface and not create a deep injury or burn. Let's go to the next slide next there. So, as we want to go and treat the periphery of this lesion. And let's go let it run. So, we'll see I'm sure a lot of no no this is the wrong video. You can go back one. Yeah, this one please. Very good. Okay. And so we'll be seeing a little bit of work with a snare tip in a minute, and some evidence to that effect but we decided to go underwater with a cold snare cold snare was already out in this case to remove up some smaller lesions. This lesion hunter snare. And so we went around the periphery and and clearly took out, you know, normal tissue around the side and we'll hear Michael's thoughts on that and in a bit I'm sure. So we decided to do this but then again what we did is similar to the techniques that were shown earlier with cold snare, we would generously use the water jet afterwards to irrigate and look at this area. And you can see it expanding in the semi close a little bit and you get a little bit of great transient bleeding but not much. Okay, and then let's go to the last video there are this little management there. So this was a patient who was going to go back and into coagulation was a left sided lesion it was a large lesion. We had a little bleeding that we encountered so we were going to close it will discuss about whether and how to close. We start out closing it with some clips. And we come up with a clipping strategy to close this thing, oftentimes grabbing at the far end and even start even further away but we started to start there. And we realized we're going to end up using a lot of clips and just wanted to show a different method of potential closing here using a through the scope suture. So we're actually going to be driving in a little bit of a sutures with a little bit of a pledge there we're going to go across and to the right and then back to the left and zigzag around and make for spots there and then we're going to cinch together and and close that down so we'll end up substantially closing this quite easy and, you know, it's a little bit wide and I think it was certainly feasible to use this and close this, but it would have taken a lot of clips. I'm not sure which would have happened any faster. But this was another alternative method and then we after cinching this together this is all through the regular scope so we don't have to change any equipment. And after closing this all together tightly you'll see we still need to put one or two clips at the bottom end, but talk real quick john about please when you're surveying this because these are going to stay on right so what's your, what, when you have something you remove piecemeal, do you feel good about having these. I would say permanent they can be removed but not easily. Well, when we've gone into surveillance I've seen some of these things at a year but oftentimes they're, you know, they're certainly they're going to be there at six months as opposed to the clips which will fall faster, but in a year, most of the ones I've done I've been, I've been, I've been out by there they're in the duodenum as well so they may be able to a day dig in about three or four millimeters or a little deeper than the what you grab with a clip as you're pulling over, so they may have some no one's shown any benefit in terms of hemostasis, but it's just in terms of efficiency so let's go and now hear from Michael about how he manages his resection sites and then we'll have a panel discussion on some of these topics and debate these things amongst us.

large polyp

resection site

controlling bleeding

closure

prevention