Welcome to ASG Endo Hangouts for GI Fellows. These webinars feature expert physicians in their field, and I am very excited for today's presentation. The American Society for Gastrointestinal Endoscopy appreciates your participation in tonight's event entitled Resection Large Polyps, Fundamentals of Electrosurgery. My name is Marilyn Amador, and I will be the facilitator for this presentation. Before we get started, just a few housekeeping items. We want to make this session interactive, so feel free to ask questions at any time by clicking the Q&A feature on the bottom of your screen. Once you click on that feature, you can type in your question and hit return to submit the message. Please note that this presentation is being recorded and will be posted within two business days on GILeap, ASG's online learning platform. You will have ongoing access to the recording in GILeap as part of your registration. Now it is my pleasure to hand over the presentation to our two GI Fellow moderators who will help with the incoming questions, Dr. Vimal Badiwala and Dr. Nicholas McDonald. I will now hand the presentation over to them. Hi, good evening. My name is Vimal Badiwala. I'm a Gastroenterology Fellow at SUNY Downstate Health Sciences University. I'm joined by my co-moderator, Dr. Nick McDonald, who's a Gastroenterology Fellow at University of Minnesota. We are delighted to have so many of you join on this Thursday evening. We'll start out with introducing our four faculty members who have so graciously devoted their time out of their busy schedule. Our lead moderator for tonight is Dr. Gautamukala Raju. Dr. Raju is a professor in the Department of Gastroenterology, Hepatology, and Nutrition. He holds the John Stirling Distinguished Professorship and leads the Charles Butt HEBGI Cancer Prevention Research and Education Center at the University of Texas, MD Anderson Cancer Center in Houston, Texas. Dr. Raju's YouTube colonoscopy education channel shares vast colonoscopy techniques to prevent and enable better detection and resection with over 1,000 videos and views greater than 3 million. Our second faculty member is Dr. Philip G. Dr. Philip G is the Assistant Professor in Department of Gastroenterology, Hepatology, and Nutrition at the University of Texas, MD Anderson Cancer Center in Houston, Texas. In 2018, Dr. G was awarded ASG Best Video Award for his video on duodenal ESD and suture defect closure across a lumen-opposing metal stem. Dr. G has also won several teaching awards during his residency and fellowship years. I'll hand over the mic to Dr. McDonald. Wonderful. Thank you, Vimal. Thank you, Vimal. I have the honor of introducing two additional of our faculty. Dr. Tanya Kaltenbach is a Professor of Clinical Medicine at the University of California, San Francisco, and the Director of Advanced Endoscopy at the San Francisco VA Medical Center. She served on the U.S. Multi-Society Task Force on Colorectal Cancer and led the guideline development for endoscopic removal of colorectal lesions. Her areas of interest include optical diagnosis of gastrointestinal lesions, endoscopic management of patients with inflammatory bowel disease, and advanced endoscopic resection of complex colorectal lesions. Dr. Jennifer Phan, she is one of our faculty as well. She completed her internal medicine and GI fellowship training at UCLA. She completed an additional advanced endoscopy year at UCLA. And she's currently an interventional and bariatric endoscopist at the Keck USC School of Medicine with a special research interest in obesity, artificial intelligence, and pancreatic ovulear malignancies. And thank you guys for being here, and we're excited to learn from you. With that, we'll turn it over to our faculty. All right. Vimal, thank you. Nicholas, thank you. And I want to thank my colleagues, Tanya, Philip, and Jennifer. And what we're going to do is I'm going to present some cases, and Tanya, Jennifer, and Phan, and Philip will discuss the cases. All right. What I've done is it's hard to teach everything in one hour. And in order to help you learn some of the aspects of EMR, I've actually compiled a set of videos and shared with you all. And I hope you found them useful. I want you to give me some feedback so that we can do a better job. All right. So what I'm going to do is I'm going to start off with this case and let one of my colleagues talk about this. All right. So this is a patient that was referred for endoscopic mucosal resection. And you're seeing the lesion under white light and also under NBI. And let me ask Tanya to comment on this. Tanya, when you see a lesion, what are your thoughts in terms of the optical diagnosis and what you see in this video? Sure. So I immediately see the tattoo. So I know someone's either referred that or seen that, and I keep that in the back of my head about the tattoo being there and what that could do. But then I look at the lesion. So it looks like a lateral spreading lesion. I'm looking first at the morphology. It's a large non-polyploid lateral spreading lesion. And it looks like the granular type of a lateral spreading lesion. And what I mean by the granular is you can see all those bumps. And it looks homogeneous. So I'm not seeing any of the morphology that looks particularly larger or particularly more concerning. It looks like a homogeneous lateral spreading lesion, granular type. And the size of it, I think, particularly for this type of lesion, I'm not as concerned about the size. I don't know how much you wanted me to get in, but they tend to lift well and things. The other thing, after I look at the sort of gross appearance and the morphology, then I would go into more about the vascular pattern and the surface pattern. And that's when I would wash some of this mucus away, look at the patterns. You have it in NBI here. I can see from what is in focus, it looks uniform. I see the tubules and I don't see any loss of pattern. Those would be all things that would make me more concerned. So I'm looking for, when I see this large lesion, I'm describing the morphology and then I'm looking for things that tell me I can't resect it. And that's kind of how I approach the lesion. I'm happy to keep going, but I'll pause there for your comments or further questions. All right. I think it's good to hear. I think basically, as an endoscopist, what we try to do is figure out whether there are any features of cancer or not, right? If there are obvious features of cancer, then we don't want to spend time trying to resect and then get into trouble, right? This lesion is one of the lesions with the lowest chances of having a cancer focus among all the types of lesions that we see. All right. Right. So even though it's so large, it's not discouraging. And the last thing I just want to comment on is I am thinking that you may be in the cecum here. I don't have all of the clues, but that looks like the housetral folds were in the appendix. So that's another key thing I want to assess. I don't know if you'll get into that a little bit more. Yeah. So let me request, Philip, when you see a cecal lesion, what's your thought process? So Tanya has a hard act to follow in terms of education, but when I see a cecal lesion, I want to immediately ask myself some of the same questions, which is, is this resectable or not endoscopically? And so what I look for is I look for my landmarks. Generally speaking, with few exceptions, a polyp that goes into the appendiceal orifice, into the actual appendix itself, or a polyp that goes into the terminal ileum itself, makes it either near impossible or straight up impossible for an endoscopic resection. And that's true for a couple of reasons. One is that it may be very difficult to lift it and resect around those areas. Two is that even should you feel that you got an adequate resection, you may set yourself for a scenario in which you're unable to survey the resection site properly in the years to come. And that's always a problem because the last thing you want to do is resect something thinking you got everything, only to be fooled and have a recurrent or residual lesion grow on you years down the road. For a cecal lesion, one of the things that immediately comes to mind is what's up with the tattoo. And I think Raju will probably get into this at some point, which is when do you tattoo? Why should you tattoo? And where should you tattoo? And I think without going into it too far, this is not a lesion that I would have tattooed, irregardless of whether I felt that it was resectable or not. Okay. Jennifer, what are your thoughts? Yeah, I agree. I mean, Tanya and Phil pretty much touched on a lot of things that it looks resectable. I think as a fellow, I would think to myself, which area is the hardest for me to do? And I would do that first. Right. So when I look at this lesion, I would most likely start kind of where the edge is furthest away from me and kind of work forward based on my skill and my talent and kind of what is the most comfortable. I'm going to say for last. The other thing that I still touched on is with how good imaging is and how good video capturing is, you know, when you have certain landmarks, you can really photo document where certain lesions are without having to tattoo them. And so even with your words and even with your pictures, you can still say a lot without causing any sort of complications or for us to make resection more complex for the next endoscopist. Yeah. All right. Thank you so much. I just want to take a couple of seconds to summarize what we have learned. This is a lesion in the cecum. Right. You know, you have the force, the crow's feet and you have the appendix and you have the ileocecal valve and there is no need to tattoo a lesion in the cecum and probably there's no need to tattoo a lesion that's glaringly obvious in the rectum. But in the rectum, you could tattoo if you think that this is a neuroendocrine tumor and somebody might miss that, that's one place where you could actually tattoo in the rectum. Otherwise, stay away from tattooing into the cecum. That's one point I wanted to share with this video. The other thing is when you see a patient like this, you say to yourself, okay, this is a lesion in the cecum and you have to take time and describe the lesion in terms of two important points. Does that lesion actually extend into the appendix deep or not? And if you can actually share that information to anyone who's going to do the resection, at least they can plan, plan that procedure better, but they can also tell the patient that this is something that we can take care, you don't have to worry. So cecal lesions, you have to comment on involvement of the appendix and like Philip commented on whether there is involvement of the ileocecal valve. So those are the two important messages in terms of documenting in your endoscopy report. If in case you don't want to resect, but you want to refer to somebody, it's a good idea and you'll help your patients come out of the consultation much, much better. Because when I saw this lesion, I told them that, hey, I don't know whether it's going into the appendix. I don't know whether I could resect this. That's not what you want to do, right? You want to tell them that you could resect. And you could say, hey, your physician checked it and he saw that the appendix is free. This is something we can resect. So something to keep in mind, all right. I want to also share a couple of things in terms of tattooing. Usually when we tattoo, we actually fill the syringe with a tattoo and then go in and try to do that. But instead, what I suggest is you get into this habit of having your catheter, flush it with saline, and then take the tattoo and fill the tattoo until it comes to the biopsy port and not more than that. That means you have at least another cc or more of saline and use that to create a mucosal bleb and then fill that bleb with the tattoo. And that way you'll have the tattoo going into the submucosa. You're not injecting through and through into the peritoneal cavity. So that is something to keep in mind. And when you think that this is a large laterally spreading tumor with the flattening, and whenever there's flattening, you think it is cancer. In those cases, if the patient needs surgery, make sure that you put at least three or four tattoos disturbed to the lesion so that surgeon can resect a little bit downstream. On the other hand, if you have a lesion that you're sending it for EMR or ESD to another colleague, you want to put a tattoo about three to four centimeters distally in the same plane. And after injecting the tattoo, take a picture to document the tattoo and the polyp in one frame and put that photo in your report. These are things that are very important in terms of providing exceptional care to the patients. And these are small things, but very important. All right. So I'm going to show you another video. And this is somebody where I'm coming back from the ASN in Poland. And I see a lesion here, right. And I want Tanya to talk about it because Tanya has done exceptional work with Raj Keshwani on how do you optimize your resection in terms of your scope, in terms of positioning the lesion, et cetera. Tanya, you want to comment on that? Sure. So the cap is useful here. I haven't appreciated the extent of the lesion in its entirety yet, but it's great. You've noticed it at 12 o'clock. So my reflex would be that I would get that to five o'clock. So the key thing in anything that we're doing therapeutically is we want to align the target lesion or the target bleeding site, whatever it is, in line with the accessory channel. We can't change the position of the accessory channel, which is at five o'clock, five to six o'clock in most of our colonoscopes. So instead of like going to the lesion, we bring the lesion to us. And that just means that we rotate the lesion to that five or six o'clock position. One thing I learned over time is that the clock face here is not the monitor, but the colon lumen, because a lot of when we say reposition it to five, a lot of people just put it like over to the five o'clock on the monitor. No, we're talking about five o'clock in relationship to the actual colon lumen. And you can see here, Raji, nicely now put it in five o'clock. And now I can see a moment ago, I didn't really see the extent of the lesion. Now I can, this is in line with my endoscope accessory channel. And now we're able to, the reason the five o'clock is important is two things, probably more, but two, two things we can remember is one, it's in line with that accessory channel. Two, I'm now able to come over and look down, right? So I'm able to like bring my snare down. And when you bring your snare down, you're able to get that apposition against the normal mucosa so you can capture it. If you're in the 12 o'clock position, you slip, it moves, you can't do these maneuvers and you can't capture it in the same way as when it's at five. So those, that's a key step, whether it's small lesions, whether it's larger lesions with EMR, whether it's ESD, any of these techniques, that position is key. So let me ask Jennifer, what techniques do you use to get your lesion to six o'clock or five o'clock position? And I want you to share your thoughts as we, as trainees try to develop their colonoscopy skills, what are the things that they should avoid so that you can actually get the lesion wherever it is to where you want it to be? So I think one of the most important things that you learn as you develop your colonoscopy skill is how important it is to get to the secum short. And so if you watch endoscopists who do a lot of colonoscopies, most of our time is actually in this pullback reduction motion to try to get there as short as possible. Because trying to do any sort of maneuvers, polypectomy, or even moving a polyp to a different direction is very difficult if you're looped. And so that's probably the biggest thing that you can do. The second thing is as you're rotating your scope, you're trying to keep your polyp in view. It's not just a blind rotation and then hope to find the polyp again. And once you've achieved that rotation of the polyp to where you want the five or six o'clock position, sometimes you can't take your hand off the scope. So I tell my fellows it's really important to be able to develop a secondary way to hold the scope as you're doing your manipulation with your snare or your injecting. And so really learning and being comfortable with anchoring your scope tip, your scope shaft itself with your pinky to keep all that work that you did to manipulate the scope into the same position as you're doing your EMR skills. And so I think those are the two most basic things that you can do as a first or second year and third year fellow as you're trying to reposition things and learn how everything translate from scope handle to scope tip. And just to follow up on that, I think those are great points, Jennifer. I think that she uses her pinky. Another accessory is our hip, right? And so you can have your scope kind of hanging. And I always joke and I say, look, I'm waving. I'm not using a hand here and my scope's not moving. It helps you if you have the scope there and use your hip. And that's where bed height is important. We think about all the things we can do in our room to optimize the ergonomics, to optimize the ability for us to have other accessories. We have two hands and one channel, right? So we need to like optimize. So I think your point about using other, like how do we stabilize it so that we have that free hand to use our accessory? Because this hand is so important for the therapeutic accessory, not an assistant pushing it. You're the one as the endoscopist. So you need to learn how that you can free this hand up so you can manipulate that snare catheter with that pressure and those things. So it's great, Raju, you bring these points up because even in small lesions, it's really important. All right. Let me ask Philip, how does he get there? Because this is probably in terms of any therapeutic procedure in the colon, I think the scope tip control is the most, most important thing. If you know how to do that, you can do almost everything. Philip? Yeah. So from my standpoint, I totally echo what Jen and Tanya have mentioned already. There's a couple of things, just being a fellow forum, a couple of lessons that I've learned over the years. One is don't be lazy and don't cut corners. So invest the time to actually get the polyp where you want it to be. And that would be at the five, six o'clock position on a colonoscope or at the six, seven o'clock position on an upper scope, depending on what kind of scope you're using for the actual resection work. But take the time to actually invest in getting this thing in the right position. And that's part, and a lot of that's because if you have it in a wrong position, and thinking to yourself, oh, you're tired, it's the end of the day, there's three other patients waiting, you're behind, you're actually going to shoot yourself in the foot with a poor position, because then your procedure will actually take even longer if you don't have a good position. Another piece of advice that I have is, again, very similar to what Tanya just said, make sure you have one hand free. So what I do is I actually leverage a lot of my big joints. I learned very early on that if you only rely on your hands and fingers, they will hurt, especially at the end of the day. Also if you only use your fingers and wrists, your wrists will hurt at the end of a long day. So leverage your big joints. You can do the exact same motions using your elbows, using your shoulders, using your torso and your hip. You can make the exact same torquing motion with all of those. And that's a lot of that comes, you know, with the scope tip control. There's a couple of other things as well. Personally, I know some people do this, I do not like having another person hold torque for me. To me, I'd rather have the control myself because there's a lot of very subtle movements that you can make that's very hard to communicate with an assistant who's holding the scope for you. So again, try to actually get into the habit of getting yourself in position. When I was learning ESD as an advanced fellow, my ESD mentor taught me something that I thought was extremely important. That is, for lesions that are in difficult areas or for big lesions, a simple warmup exercise you can do is put an instrument out like a pair of forceps or a snare or tip or whatever and see if you can draw a circle. See if you can trace a circle around this thing. If you can trace a circle around the lesion, you have good control. If you cannot trace a circle around the lesion, you may want to see if you can optimize it further if you can. Okay, that's really very good. Thank you. The reason I wanted to spend time on this aspect, you know, everything else is easy. You know, EMR, there's not much to it. If you know how to get your scope under good control, you can do a lot of stuff. One of the things is when you do your screening colonoscopies you reach the ileocecal secum and you are in front of the ileocecal valve. Try and see if we can just rotate the shaft of the scope in between your two fingers. And if the ileocecal valve is at three o'clock, by just rotating, you should be able to bring it to six, 12, sometimes you can bring it down to nine, 12, or even back to three. If we can actually do that, that means you have mastered the art of a short straight scope to the secum. And that is something you want to get into the habit. And if you can master that, you will do a lot of therapeutic work without losing sweat. Why don't we do one thing, Nicholas and Vimal, if there are any questions, let's take it. And then before we go to a complete case of EMR. Could I make one final comment? Please. We can't overemphasize this scope stability and positioning. And I think like as a fellow, if you practice, as Roger is suggesting, like be purposeful in every colonoscopy that you are being deliberate in trying to get this position. We deconstructed the steps, for example, of cold snare polypectomy. This step was the hardest step, getting the position to five o'clock. Once someone got that, just as Roger and everyone said, then the rest of it is much easier. So I just think if you can prioritize this technique, it really will play into all of your other endoscopy maneuvers and therapies and such. It's just, I don't know how much more to overemphasize this step because it's not an intuitive one. It's a critical one, but it's very hard to learn. So don't be discouraged. It's something you got to practice again and again. I appreciate you guys answering some of the questions in the Q&A box and for our attendees, if you guys have questions, perfect to get some answers for you guys. But so we can all benefit from some of these good questions. One of our questions was, do you recommend tattooing proximally or distally to lesions? I think it's always get into the habit of tattooing distally and you have to, you have to document that you tattoo distally and also important to take a photo of the tattoo and the lesion. And usually what happens is the surgeon is going to look at the tattoo and then go maybe five centimeters distally and then cut it. If you put a tattoo on the proximal side and the guy has not reviewed your nose, there is a possibility that he has not removed the collar and it happened. So important to tattoo distally and more important is to take a photo and document the polyp and the tattoo. Certainly, Dr. Raju. We have two more questions on tattooing as well. One is how many mLs of tattoo you would inject into each blood? You can inject actually, you know, I've injected two mL to three mL or five mL as long as I create a submucosal saline bleb. When you create a bleb, you know that you are putting your tattoo into that submucosa and not pushing it into the peritoneal cavity. I've injected two mL, three mL, in some cases five mL as long as the bleb is happening and that is for cancer marking. If I'm planning to do a tattoo and refer the patient for EMR, I will put a very small tattoo because the tattoos do migrate, right? You've done the patient on the supine left lateral position and then the guy wakes up and the tattoo is going to migrate. So important to- Your tattoo that you showed in that CECOM, I mean, that's a perfect example. You think you tattoo it locally and then time goes on and it dissipates, right? Over and over. So I think your point's critical about thinking about what's the intent and how much then. All right. One more question in the Q&A and then one in the chat box. Question from Q&A, why don't you tattoo a lesion in the CECOM? So I can answer that question. As an endoscopist, you ask your school, you know, as a person doing the tattoo, you wanna ask yourself, what are you accomplishing by tattooing? Are you marking it for yourself? Are you marking it for another endoscopist who's gonna EMR or ESD this thing? Or are you marking it for a surgeon to resect? If you're marking it for another endoscopist, you gotta ask yourself the question of, is this really something that the next endoscopist is gonna miss? I can tell you as a endoscopic resectionist that I'm not gonna miss big polyps that somebody else finds, especially if I know that it's there, especially if the referral says that it's there. So automatically, if you're gonna refer it to another endoscopist, unless it's something really, really confusing, I would not tattoo it. Now, for the surgeon, you should tattoo it for them if you're gonna send them for surgery, but you should always describe exactly where. Nowadays, with probation and other note-writing software that kind of writes the note for you, it's really easy to just click a bunch of checkboxes and have this thing pop out. But I think Tanya and Raju and maybe even Jennifer have probably all seen an endoscopist and I think Tanya and Raju and maybe even Jennifer have probably all seen and experienced the same thing, which is a wrong site surgery where a surgeon goes in and cuts out the wrong side of the colon because they thought that the lesion was whether proximal or distal to the tattoo because there was no mention in the note. So wherever you do tattoo, please take the extra time to actually document where the tattoo is. Now, for the surgeon, why wouldn't you tattoo in the cecum? The cecum is the easiest place to find in the colon, in the abdomen. If you've ever done laparoscopy, you can't possibly miss the cecum. So it's kind of like, if you wanna tattoo the cecum, a lot of times surgeons will tell you, well, instead you sprayed tattoo all the way out into the peritoneum and you made a big mess in the visceral peritoneum instead. So for obvious landmarks like that, I would not tattoo the cecum. Wonderful, thank you. We're getting a lot of really good questions in, but maybe for the sake of time, we'll move to the next case and we'll kind of keep trickling these in and certainly at the end, keep going with the Q&A. Okay. So let me run this case and I'll ask Jennifer to comment. Probably, I think, Jennifer, as you see the lesion, your thought process, and this is a lesion that was referred to me for endoscopic mucosal resection. And this is in the ascending colon. Great. So it looks like I see a 15 sub two centimeter lesion in the ascending colon, pretty flat, probably a 02A on Paris classification. As you're so skillfully drawing the borders out of what this polyp looks, where the polyp is at. I think it looks good for a pretty straightforward resection. Thankfully, no one has tattooed this area. And so I would start injecting with a lifting agent and seeing how it lives. But my suspicion is it's going to lift quite easily. And the hope is that based on the size and the location that you can be able to get this on block. Okay. All right. Tanya, what are your thoughts? I agree. I would just make sure that the borders I appreciate it entirely. I would get it in that five o'clock position. I'm not seeing any concerning features. I agree with Jennifer's classification of the morphology. It looks like a lateral spreading. Non-granular type. Sometimes they can be difficult to lift, but this doesn't, this I agree. It looks like it's going to be able to lift up. And then we'll see how sometimes when you lift it it does get larger. So we do want to be mindful on block is great but we should also not be greedy. So piecemeal EMR also has good outcomes. So just something to consider how large we can how much we can get in one piece. Okay. All right. So in terms of the injection I think probably fellows will have questions. Why don't each one of you share what is your preference for injection and how are you going to inject? One place, two places, multiple places. So let's start with Philip. What is his choice of fluid for injection? So for me, I like using one of the especially for a polyp like this where I'm going to consider doing an EMR. I like using one of the sort of the high vis commercially available, like high viscosity kind of bluish tinged fluids. There's several on the market right now. There was Ellevue, there's Orize, there's Everlift. There's a number of different lifting solutions on the market. There's also, you can just mix your own saline with methylene blue as well or saline with indigo carmine. I like the blue, not just because it's visually pleasing but because with the blue you can tell apart submucosa from muscularis propria. So that's the type of solution that I like to use. One other thing that I will comment on that I think was kind of touched upon is in terms of choosing, and this is also a pretty popular question in the Q&A right now as well, is what kind of method to resect something with? As an ESD person, I will be bluntly honest with you that you should resect with whatever you think will give you a complete resection. So whatever it is you choose to resect, make sure it's something that you're comfortable with. Make sure that it's something where once you start, you're able to finish. One of the worst things you can do to another person is to incompletely resect and then give them the leftover. So whatever you tackle, you wanna tackle it knowing that you can actually finish it. And there's no shame in not being able to resect it. That's okay. There are polyps that Raju and I have not been able to resect and that's okay. All right. Jennifer, what is your choice of fluid? I echo what a fellow said. I also like to go, I typically go for Elevue as my choice of fluid. But what I wanted to, what you keep showing here for your injection technique is something that I really like. And something that I have my fellows do is some of the fellows will like push that needle in pretty deep when they're trying to inject. So here you can see kind of a flash of fluid as you push in and then you push in the needle. And so that way as fluid is already kind of injecting and right when you see that blood happening, you know you're in your pocket. And so I kind of like them to inject a little first before I poke and then it expands. And so that's something that I have my fellows do when they're doing EMRs with me, big EMRs with me is to do that technique. And then in terms of where you're injecting it was also a great choice. You wanna inject it in an area that you think, one is if anything looks more excavated or at all deeper than any other area, you wanna inject that area first. And in a lesion like this, injecting somewhere in the center with a good blood can really kind of bring that up to the surface. Tanya. Great, I agree with everything that's been coming on. I think I just would like to further comment on your injection technique. So for a lesion like this, I think saline with indigo carmine is fine or if over two centimeters, the viscous solutions are helpful to take, to kind of get it and have a, the viscous solutions are more so your blood stays. And so in the kind of ones around two centimeters, you're probably gonna be able to resect this fairly quickly. So saline is enough. But what I wanna really comment on is your technique. So as Jen said, you're popping it in and you're getting it into that submucosa, you know your space. And then you want, you're staying right under the mucosa. You're like in the superficial submucosa there. And as you inject, you're pulling your needle catheter back to stay there and direct the fluid. So you're like pulling and creating the bleb to you as opposed to like pushing down and the fluids going like, the kind of dissipating out. You're helping facilitate that bleb formation. And that's really key there. And when you do that dynamic injection, there are like three steps, which you're showing. So maybe I'll talk them through when you say you're pushing the needle in, you pull the needle catheter back slightly as you're injecting, and you tip deflect to the opposite wall. So that allows for that pulling still. And then lastly, as you're suctioning some, because if you have your lumen really, really distended, then it's not as pliable and you're not able to inject and create the bleb. So those three things to think about are really great things to think about as you inject, because injection, I think like can be an enemy if you have a poor injection. So thinking about making injection your friend and making a non-polyploid lesion polyploid is the goal of injection. So that you can kind of get that snare around more easily. So this is a beautiful injection, Raju. It looks, I'm just curious, this is saline with indigo? Yes. Yeah. Yeah, I actually use saline because I'll show you why I use saline. So if you look at it, I picked a 15 millimeter snare, a stiff snare. And this is an unedited video from the beginning to the end of the resection, all right? So the stiff snare is probably the snare that you should pick because it is more stiff. You can see that, right? Because of it is saline, it is a little bit softer. It's almost like a soft pillow. So I could put my snare and then rotate, right? I was basically rotating my scope for the snare to come onto the lesion. And you can see that you lost sight of it a little bit because of the lighting and then able to grasp the whole lesion in one piece. And before you cut, it's important to release your snare a little bit, as you can see here. And distend a little bit for the muscle. If it were trapped, it will fall back and then cut. I use the Endocut 313. The moment I cut, I want to make sure that I have a nice submucosa and the edge looks good. I want to document my resection. And I actually document in my colonoscopy report, every polypile I resect, I document the base. And even if I do a cold snare, I document my resection base. I think it's a good idea to get into that habit of telling the whole story of how you managed a particular polyp. Whether it is three millimeter polyp, I remove with a jumbo biopsy, I want to document my edges are clean with no recurrence. So something to keep in mind. And for the sake of time, I will move forwards and then for the last 12 years, I've been ablating the edges routinely with APC. Here you're using APC. This is a pulsed APC. There are two types of pulsed APC. One with multiple frequent pulses. The other one is a little bit infrequent. And I try to use at least a 35 Watts, 0.8 liters of flow and get a nice brown effect. That way, if there are cells that our eye cannot see, you can actually get rid of them, right? And with this technique, you can actually assure yourself complete resection. And the other thing is, pathology may come back and say margin is positive, but you know that your endoscopic cut margin is clean. You can be confident and say, hey, my cut margin is free. I'm looking at the outer side of the cut and the pathologist is seeing the inner side of the cut. And pathology margin positive doesn't mean a damn thing, as long as your outer margin is clean. Plus, if you ablate, you can be assured that this patient's polyp is not going to come back. So, and, so let this video play in terms of clip closure. And I wanted to ask like Jennifer to comment on how does she close the defect with clips? Or, and I want to ask Phillip to comment on, you know, he has been using the suturing device a little bit for larger resections, not for smaller ones. And maybe they can comment on that. And then we can take questions so that people have lots of questions that we can answer. Yeah, so I think there's a lot of clips through the scope clips that are on the market. So knowing, it depends on the size of your lesion. So here you have a pretty reasonable defect. Defect. And so you can use an average size clip when you're 12, when you're 13. Sometimes when we have larger defects, you want to reach for some of the larger clips in order to really get both sides of the mucosa that are on the edges of your defect. And what you want to create is exactly what's being shown here by Raju is that you're getting this shoulder effect. That you're getting kind of mucosal to mucosal opposition and that you don't see any of the blue, any of your injection material in between. So it really facilitates closure of your defect. It decreases your risk of bleeding because you're actually creating some tension and some pressure with your clips there. And so I'll commonly just use a through the scope clip. And then there's a couple of other new devices that have come out for EMR defect closures and ESD closures. So I'll let Phil talk about that. But again, the goal here is not to just do a superficial closure, but to create that shoulder that you see there. So for me, just like with the Q&A and people asking about EMR or ESD or whatnot, my answer tends to be, do what you think you're comfortable with and do what technique is going to let you do a good job. So if you have a resection defect like this one, where it looks very favorable for landing clips on, you want to use clips. There are occasional times where I've run into positions where clip closure is extremely difficult, where no matter where you clip, you kind of get the feeling that you're missing the back edge. This can happen sometimes with lesions where it's predominantly behind a fold, where you think to yourself, you're clipping the front, but are you really closing the back? In those situations, knowing some of the newer technologies that's out, including there's a new suturing device, like a helical tacking suturing device called the X-Tack may come in handy. In general, with suturing devices, there's a pretty significant learning curve to it. So I would say, unless you're really proficient at it, unless you use it all the time, this is not something where it's like, well, I don't think I've ever used this before. Let me just try it on this really hard lesion. That's probably not the right place to start using something like that. But I think the general principle that, I think Raju, you can tell me if you agree or disagree, or Tanya as well, is, use a technique that you're comfortable is going to do the job completely, right? If you're gonna use clips, I tend to teach what's called a zipper closure. So in other words, you don't start in the middle of the defect, you start right, not even along, not even at the corner, but slightly outside. Thank you. Start slightly outside the defect and kind of zip up the defect, if you will. And that's called a zipper closure. That's what I have to say. Any comments, Tanya? No, I think they said it well. Sometimes it's, I think that sometimes the size is often maybe too large even. So, but the suturing devices, particularly the new one that Philip mentioned that's through the scope is more attractive in that, cause often would be hard to come all the way out and go in with a suture device to the right colon. So. Yeah. Yeah. I think one of the things that I want to share with our junior colleagues is this. Basically, when you think about EMR, there are only basically three things, right? One is going to the sacrum so that you have scope tip control. When I say scope tip control, if you rotate your hand by two degrees, the tip should rotate by two degrees. If we can do that, we can do a lot of stuff. Number two, learn to figure out the optical diagnosis of the polyp, right? You know, and there are lots of resources that are available out there. You know, what are the features that make you think, okay, this is cancer or not? Okay, obvious cancer. And the third thing is, you know, inject and cut. There's not much to it. And if you think that the polyp looks benign and there's no features of cancer, then the outcome of resection, whether you cut it in piecemeal or end block is likely to be very good. Probably you can get 95% eradication rate whether you cut it end block or piecemeal, as long as you cut it clean. And the base looks like, irrespective of the cut, looks like a clean base with nothing there. All right, why don't we just leave it here and let's open it up for questions, Nicholas and Vimal. Hi, Dr. Raju. One question that has come up, an important question is, what lesions do we use clips to close both EMR? Okay, so if you look into the literature, you know, patients who are likely to, there are two things, right? One is prevention of a bleed, delayed bleed. And the second one is prevention of a delayed perforation. So I'll come to the prevention of delayed perforation first. If you read Michael Burke's work, I think it was published in Gut, where he talks about depth of the resection. Say, for example, you inject methylene blue or indigo carmine solution, you know, either saline or one of these solutions, and you reset and you see blue matty area of connective tissue, you know that the resection plane is limited to submucosa. Submucosa, as long as it's intact, that is one of the strongest layers in the colon wall. And if that segment is intact and you have not spent too much of current to cut, you can be rest assured that that patient is not going to have any perforation. On the other hand, if the resection depth includes muscle and there's muscle damage, that patient is likely to develop a delayed post-polypectomy syndrome or even delayed perforation. So muscle injury, you should always close. That is from the perforation prevention and management point of view. From the delayed bleeding point of view, we know that right-sided lesions, large lesions, lesions in patients who are in anticoagulants are at high risk for delayed bleeding. And those things are important to close. I do close almost every EMR that I do, large EMR, especially if they're coming from far off, even if they're on the left side or in the rectum. And if you want to close, you can have an impact as long as you close and create a deep approximation. That means the clip actually, the blades go deep into these and be able to reach the submucosa. If you close and you see gap in between the two blades of the clip, that clip is not going to really do much to the deeper submucosal vessels or even stay there for longer period of time to prevent bleeding. So that's not really, if I put a clip and my clip is for some reason showing a gap, I know that clip is going to fall off and I want to put a deeper clip on either side of that. And let's see what Jennifer and Tanya do. And let's hear what Philip does in terms of clipping. Jennifer, when do you clip? I'm sorry, I was answering questions. There's so many great questions in the Q&A section. So yeah, I also clip a significant portion of my EMRs, especially if they're two centimeter defects and if they're in the proximal colon, that pretty much will get a clip to a zippered defect if I can do it. And then if a patient is on anticoagulation that needs to resume anticoagulation quite quickly after EMR, I also will just do prophylactic clipping as well. So everything that you said, Raju. Right, Tanya? Yeah, I agree. And I just would take the moment to emphasize again, the clipping too, like it requires, don't start a case unless your scope is stable and you have access to the lesion in a very controlled way. Because if you have this like awkward position and then you try to cut it and then there's bleeding or you can't see the defect to assess for how deep you cut, all those things will get you behind. And so kind of going back to those basics of like, make sure before you do any of these things, whether we're injecting or cutting or clipping at the end inspecting the defect, we have to have that stable scope position. Because as Raju is talking about these deep grabs and Jen's talking about the shouldering, you can achieve those if you're like, in the hepatic flexure, clipping the cecum, like you've got to be close to the lesion having control. So going back to that initial practicing of getting that five o'clock, it all comes back to that. All right. Wonderful. One of our other questions from the Q&A, in regards to APC on margins after resection, how big does a polyp have to be in order for you to do APC of the margins after resection? I think the most important thing is, first of all, you want to first cut the polyp so that when you look at the margin, the margin should have the round pit pattern. If you see a round pit pattern, you know that it is a normal crypt adjacent to that. That is one thing. You should not APC if you see residual polyp there and try to burn that. So you want to make sure that your resection is complete and you're seeing a healthy mucosa with round pit pattern. And after that, when I started my practice almost 13 years ago, I said to myself, I'll keep it uniform and I APC everybody. But now there is some data to show that you can do this. You can achieve the same result with less recurrence by doing a snare tip soft coagulation. By doing that, you'll probably save yourself and the patient some unnecessary expenditure. So you can actually do the APC. I try to APC all lesions that are at least 20 millimeters or more for sure. And all I can say is, you know, when you're trying to do something, it's better to do it uniformly and stick with it and see what your own outcome is going to be. And that way you can make changes and improve. All right. And by doing APC routinely since 2009, my recurrence of large polyps that is 20 millimeters plus with EMR is about three to 4%. And if the patient has never had attempted resection, that recurrence rate is even probably even low. Why people have recurrence? I think my own guesswork is, they're not spending time to document. The margin is completely clean. The base is completely clean and they're probably rushing through. Thank you for that, Dr. Raju. There are so many excellent questions here in the Q&A. We'll take one question that was answered in the Q&A by our faculty members, but for our audience benefit, what are your guys' thoughts on taking biopsies of such large lesions? So, you know, we can start off with Dr. G and then go to Dr. Calton back since they gave it a try in the Q&A. So, personally for me, I found that taking, it kind of depends on what you wanna do. Like if you are thinking that you're gonna refer to an advanced endoscopist for an endoscopic resection, having good photo documentation is probably better than biopsying. Just because, you know, with biopsies, you're gonna get a lot of, you might get a lot of sampling and it may not necessarily pick up areas of advanced pathology. If you're not really sure what you're gonna do with the lesion, I would say that, you know, just taking some standard biopsies, it doesn't create, I've noticed that it doesn't create that much fibrosis to the point where a resection is not possible. However, that's only for standard biopsies. I don't think it's gonna create that much fibrosis only for standard biopsies. I would not hot snare biopsy something. I would not hot forceps biopsy something. Generally speaking, as soon as you apply heat, that's what causes a lot of fibrosis. I would agree. I think that the biopsies are usually not informative. The picture tells us what it is. So it's not really helping so much. The only thing is if there's concern about advanced pathology or something or may change the management, then biopsy. But I think we know from the pictures and patterns what it is. So don't biopsy to help is kind of the message. It doesn't help. If anything, sometimes it may hurt, but simple biopsies rarely, but it doesn't help us. So it's kind of like, why? Except in those rare cases where it may change management because there's concern about, you know, deep invasion or invasive cancer. That's why I said, Tanya, can you recall one of our Japanese colleagues that worked with you and Roy who wrote this article on optical diagnosis of different findings of cancer? Do you recall that article? In the colon? Yeah. Maybe Ikahara. Right, right. Was it in techniques in GI endoscopy? Yeah, it was in techniques. I can try to find it so you can share with the group later. Right, because that article, I want every fellow to actually watch those pictures again and again, and it will help you be confident and say, hey, this is cancer, this is not cancer. You will actually benefit a lot by reading that article, which has a beautiful color photos of subtle findings that make you think, hey, this is not just a benign polyp, but it could be cancer. These are all really good questions. It's, I think, good to discuss this. We did try to address a lot of these questions in the MSTF document on endoscopic resection. So I think after being a part of this, if you look and see some of the questions and statements, they reflect a lot of the questions that you're asking in the session today. So it may be a good resource following this hangout. Probably not a bad idea to send the document to people. Maybe Marilyn can distribute to the group. Okay. Right, I think it's a good document. I actually read it a couple of times. It's a beautifully written document. All right. All right, I think we have a couple more questions if we have time in the last few minutes here. Do you prefer avulsion with hot biopsy or cold forceps if you're removing residual lesions following post piecemeal resection? So a couple of things. I think before hot biopsy, I think Greg Haber described hot biopsy avulsion. If I recall it correctly, that was probably in 2013 or 14. And prior to that, I was using cold biopsy avulsion. Problem with cold biopsy avulsion is the moment you take a biopsy, it will bleed and you'll be dealing with a little bit of bleed and you don't know whether there's any residual tissue. Right? So after 2014 or 15, once I've listened to Greg Haber, I actually changed to a hot biopsy avulsion. So a couple of things. You want to change your setting to endocut I instead of Q. Q is for snare, I. And I keep my effect very low, not two or three. I put my effect one. That means there is no coagulation in between your cuts. So effect one is just a cut, cut, cut, cut with no coagulation. And I keep my duration maybe three or four so that I have a longer duration of cut and my interval between the cuts, you can leave it wherever you want. So by having that setting, it's very important to hold that area and lift it so that there is a little bit of tension on the polyp. And then you just tap, tap, tap on the yellow pedal and it will nicely cut. That is something that's what I've actually done for a lot of polyps that are tethered to the wall, either because somebody biopsied with a jumbo biopsy and there was a scarring and you could actually cut very nicely without worrying about any deep thermal injury. And the key is you're setting, tenting and then tap, tap on the yellow pedal. So you're not putting your foot on the pedal and pressing it like your regular EMR. You're just tap, tapping. So that makes a big difference. Yeah. You know, one of the things is we are talking about a biopsy or not biopsy. If you biopsy a lesion versus you don't biopsy a lesion, if you saw, if you actually, you know, this patient was referred to me by one of my colleagues, the last one, it took only two minutes to cut. And if in case the lesion was biopsied, there will be scarring. And then what happens is depending upon where you take the biopsy, it will lift on either side and will keep closing like a book. And you'll be spending maybe half an hour to 45 minutes to cut. And then you may have to use heart biopsy evolution. Lot of unnecessary work. Thank you, Dr. Raju. We have one other excellent question that I believe the audience would benefit from your responses. In a pedunculated lesion, if surface characteristics are in favor of malignant change, do you suggest ESD slash EMR? So I think if we could just, you know, briefly endoscopically just describe what would be some of the surface characteristics that would suggest malignant change for all of our benefits. And then the second half of the question, ESD slash EMR. Thank you. Yeah, I think about your polyp like a, like a, how do I put it? You know, I come from India. I think about ball, badminton ball, which has got the, Vimal can understand that. So it has, it's a, think of a pedunculated polyp that is almost like it has to have a symmetrical shape. Whenever a polyp loses its symmetry and there is some retraction, then you should think that there is cancer. Whenever there is cancer, there is going to be desmoplastic reaction in the submucosa and then the surface gets pulled down. And when you see that pulling down, then that's one area, that's the area that's likely to have cancer. And when you think that, say for example, you look at a pedunculated polyp and the polyp looks okay, and there's no retraction, where you put your snare on the stock really doesn't matter. But when you think there is cancer in a pedunculated polyp, I want to get my snare as close to the base as possible. Base means towards the colon wall, because the margin, the distance from your cut to the cancer will determine whether that patient is going to avoid surgery or will require surgery. So you need to have that a thousand micrometer distance, at least a one millimeter or more distance. And as long as there are favorable features, like this well-differentiated cancer, no lymphovascular invasion, no budding of tumor and a one millimeter or a thousand micrometer distance from the cut. In terms of EMR or EST, most pedunculated polyps that we see in our practice can be cut with a snare, right? You can basically use a hard snare and cut it. And if the stock is too thick, I would inject some AP beforehand and I want to have my clips ready. And if the stock is pretty long and then I may use a loop after I cut. In some cases, you could actually use like a scissor type of knife to cut it. So EMR or ESD are the techniques that are used for flat lesions and sessile lesions. Is that right, Tanya? Yeah, and in my practice, I agree. In my practice, I tend to loop. I really think that looping gives me confidence that I've ligated the vessel. I may get as close to the lumen as possible, the wall as possible. And I do it before cutting because I can see the ischemic effect. I cut and there's not bleeding. And then the loop is there and stays behind to decrease delayed bleeding. So that's my practice for pedunculated polyps. And then to echo your point about cancer, I mean, if I'm going to have cancer in my polyp, I want to have it in a pedunculated polyp because the chance that it invaded down, right? We have still a chance to cure it more endoscopically because of that stalk. So I do think that morphology does change our management. Pedunculated are usually snaring at the stalk and then yeah, flat or sessile is EMR in the majority of cases. Philip? I mean, I have a bit more of an ESD slant to things. So for me, depends on how thick the stalk is. If I find that the stalk is really thick and really vascular, I'll use a scissors type knife and take it the ESD way. Basically that way I'll coagulate all the vessels and take all the vessels down as I go along. But I'm assuming you clip after that then. Yeah, after resecting, I'll either clip or I'll suture. I'll do something to close up shop afterwards. Jennifer? Agreed. I think I echo everything that Tanya and Raji said. I don't do ESD, so I do exactly what you both do. Yeah. And then I guess I think, Phil, it is true. Some of those really, really thick ones, you can't get something around so the ESD is important. But I think for the fellows, what I find is like everyone talks ESD, ESD. Like in the colon, ESD is so uncommonly needed to cure lesions. So I really like, I just feel like there's this like a projection of like, we can't cut something out because it needs ESD. That's not true. Like the bulk of lesions, whether they're pedunculated, flat, sessile, irrespective of their size can be removed curatively with endoscopic mucosal resection in the colon. And ESD is certainly needed in some cases. And I do it like IBD lesions or non-lifting ones or things like that. But I just think sometimes in clinical practice and endoscopy, we all talk about like these, these like foreign techniques that are unachievable when the bulk of us should just learn simple techniques, which is cold snare polypectomy and inject and cut EMR. And we will send a lot less patients to surgeons and we will send a lot less patients to referring endoscopist because we can do this as we graduate. It's, I think it's just something we should really focus on in our training. And then certainly we need Phil and others for these very rare lesions. But I just think the takeaway message is that most lesions in the colon are benign, can be removed with these like techniques that we can do as gastroenterologists. They're achievable. And to echo Tanya's point, I very, very respectfully agree with all of that because even with a major ESD slant to my practice, I actually discourage it in terms of most lesions, especially for phallus. There is a very big trap. It's a very attractive trap, especially amongst fellows. And we see it all the time in people who are applying for advanced endoscopy fellowship. Everyone and their mom just wants to learn ESD and ESD, ESD, ESD. And you kind of ask yourself, are you learning this for the disease or are you learning this because it's the next sexy thing that sounds really challenging? And we're all super high achievers and we all like challenges. And I think it's important to ask yourself that question. In my opinion, really, it's complete resection. You wanna achieve a complete resection whether it's piecemeal or not. There was a question that floated around on the Q&A about what is the, and I can kind of tell where the question was going. It was like, what is the recurrence rate of EMR? I will tell you right now, Raju's recurrence rate is less than 5%. Raju's recurrence rate is better than a lot of ESD recurrence rates, especially in people who are potentially learning how to do ESD. So, I think to a lot of our points, and I think I've kind of taken this a bit more of a neutral tone for this entire webinar that really the take-home message is these are all tools in the toolbox. Pick the one that you know how to do, pick the one that you know will deliver the complete product and a complete closure afterwards. One of the things that I want to help you all is this. I'm going to present one case with the thought process that went behind the scenes and managing a particular case so that you could use that in your practice. And I'm going to post every week one video. Previously, I used to post videos with no audio because it takes a lot of time to go edit and put audio. But I think from this week onwards, I'll post a video with an audio commentary about why I did what I did. I hope that will be helpful to you. All right, Nicholas and Vimal, anything else? No, just thank you guys for your time and being here and answering all these questions. It was definitely helpful for us. And I think we all really benefit from this. So thank you guys for your time and having us here. All right, Vimal, thank you. Nicholas, thank you. I want to thank my friend, Tanya, Philip, and my new friend, Jennifer. Thank you so much. It was fun. I've learned a lot. And I want all of you to be active participants in ASGA. It's a fantastic organization. I've benefited a lot, not just in terms of learning, but also developing new relationships and friendships. And make sure that you all stay safe. We all need you. All right, take care, bye-bye. Thanks so much, everyone. Thank you to all the panelists and moderators for tonight's presentation. Before we close out, I just want to let the audience know that our next Endo Hangout will take place on Thursday, January 6th, 7 p.m. Central Standard Time on management of acute GI bleeding. At the conclusion of this webinar, you will receive a short survey, and we would appreciate your feedback. Your experience with these learning events is important to ASGE. And we want to make sure we are offering interactive sessions that fit your educational needs. Another event that I would like to highlight is actually scheduled for tomorrow on Friday, December 3rd at 8 a.m. Central Time, entitled Endoscopy Live, Gerd and Barrett's Esophagus. This complimentary virtual event will feature live endoscopy cases from various state-of-the-art centers from around the world. There is still time to register. In closing, thank you again to our panelists and moderators for this excellent presentation, and thank you to our audience for making this session interactive. We hope this information has been useful to you. And with that, I will conclude our presentation. Have a good night. Thank you, Marilyn. Thank you, Lyle. Greatly appreciate it. Thank you. Bye-bye. Thank you. Thanks, everyone. Have a good night.

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