Okay, good. So, it's a big, it's a big file, so it might take a while to... Anyway, so once... Okay, this is what I'm going to talk about. So, optimal snare resection technique, which is critical to avoid recurrence, thermal ablation of the margin, the Sydney Deep Mural Classification System, post-resection defect evaluation, closure, and to mitigate bleeding and perforation, all that in eight and a half minutes. So, EMR is definitely the standard of care and margin thermal ablation is a critical component at the present time. Optimal EMR technique is critical to set yourself up for zero recurrence. In our department, our recurrence rate after EMR is zero. So, how do we do that? So, here's a large polyp. And so, generally, you want to take the dominant module first. I'd like to be able to work the video, but anyway. So, you chop that off first, aspirate gas, and then work sequentially from where you enter the submucosal plane. If you make a mistake, excise that area straight away. So, otherwise, you might forget. So, you'll see here, I make a mistake at this moment. I've left a little bit of adenoma at the edge here after this injection. And so, take that off straight away and take it large. Make the defect as large as you like. Don't worry about excising normal tissue. If normal tissue is in the way, excise it. Now, this is the critical point just here. Align the snare with the edge of the advancing mucosal defect, impact the snare, and then aspirate gas, get the tissue to bounce up, firm downward pressure with your up-down, get the tissue to bounce up. And in fact, when you do that, the risk of deep thermal injury in the resection overlap zone is less than it is at the periphery because the transection speed is faster. So, and we show that in an animal study, if I can go to the next slide, in an animal study of 88 paired resections, we looked at APC versus snare tip at the margin for ablation, snare tip superior. And also, we showed that resection in the overlap zone in the center here was less deep injury compared to at the margin because the speed of transection is faster. So, that was published in Gut. So, when it comes to thermal ablation of the post-resection margin, so this was, in fact, this was the honeymoon period, and this is my younger self, and this is with my partner whose first name was Snare Tip. And we got on very well, but things weren't perfect during the honeymoon, even though things were promising. And so, and our recurrence rate was around 5%. And then subsequently, that was the gold standard. What I just showed you there was the gold standard for tissue resection at the time. But look, this is what I held up as the gold standard, but it's imperfect. And in fact, what you need to do, at least with snare tip, more is better. Generally, less is more for a lot of things in endoscopy, but more is definitely better. It's a light touch technique, and we know now that it's extremely safe. So, in the large multi-center trial, the risk of recurrence was only 1.4% in a thousand lesions, not just stuff done by us at Westmed, but other centers, I mean, of obviously all of them trained by me. But nonetheless, it's very, very safe. And if you have high quality EMR, you can eliminate recurrence in your EMR practice just by this simple technique, making sure you treat the margin, use the water jet to expand the defect. And this has also been demonstrated, this is the large multi-center trial where the recurrence rate was 3%, 1.4% if we did complete snare tip. And the relationship continued and got better between myself and snare tip. And even in Israel, you can honeymoon there. And they were able to show in a separate study that recurrence was reduced to 3% by using snare tip compared to their historical cohort. So, snare tips to go, high quality EMR, snare tip, intra-procedural perforation. We used to be worried about this. This is instrument-related perforation. Now with the current armamentarium eclipse, don't let the risk of perforation inhibit your ability to completely resect the lesion because you should always be able to close the defect. The thing that's more important is classifying the post-EMR resection defect to make sure that you don't miss type 2 or 3, in which case those patients will get a delayed perforation. So, here's a large scarred anastomotic polyp. After we resect the lesion, you'll see that there's a subucosal fibrosis across the anastomosis. You don't know that you haven't injured the muscle there because you can't interpret the post-EMR defect. So, we just routinely close that with clips. Another example of a scarred area, we routinely close that with clips. So, that's very important. That's Sydney classification DMI type 2. Slide advance. Yes. Now, here's a video. This is a serrated lesion with dysplasia. See the serrated lesion at the 12 o'clock and then dysplastic focus. So, this needs to be removed on block, which we do do. I can get to here. We're going to take it off in a single piece. And then you'll see we'll end up with DMI type 3, which is the target sign. So, a white quartering ring inside the white quartering ring of mucosal incision. You see the white quartering ring of muscle excision. Then we're going to close that. How do you close it? You start by looking where the fluid pool is. Fluid pools up on the left. So, we start at the top. If we start at the bottom, the stem of the clip will fall across the wound and it'll make it more difficult. When we have a DMI, we like to get the clips close together. So, we usually put three, four clips. You don't have to close the whole defect. You just have to close the muscle defect. So, not the mucosal defect. So, just like so. And you can see that they're subtle. These features are subtle. So, here you see a DMI type 3. Again, target sign in the transverse colon and they're the risk factors. So, transverse colon location, fibrosis or scarring, high-grade dysplasia, and attempted on-block resection are the risk factors for DMI type 3. Can you just advance the slide for me? There we go. So, then if you do have deep mural injury, based on nearly 4,000 cases and there are 100 targets or perforations in this series, you can still go on and do the resection and all the patients can go home the same day. You don't need to worry, provided they're fine and recovering. So, don't let that inhibit you. And then finally, delayed post-polybectomy bleed. Big problem for the patient and also the staff in the endosuite. It can get really messy. So, if you are treating it, you've got to be precise. So, here we have to get the clip in the right position. And to prevent it, all the data now shows clipping in the right colon prevents post-EMR bleeding. The risk factors are right colon and intraprocedural bleeding. This is HICO's study published in Gastro in 2019, 900 patients. Same results as our own study, 9% to 3% with proximal polyps, no benefit in the left colon. Important to note. So, in our own study, it was from 11% to 3% published in clinical gastro hep, no, no, in the Lancet gastro hep. And then in the random, in the multi, in the meta-analysis, the three big trials, all showing the same results, clearly right colon polyps, you've got to close the defect. Now, it's easy when it's this size. And I ask, I recommend that you use the scope or the cap to deflect the clips back to make sure that you've got full clip closure. But when the defect becomes larger, it becomes more difficult. Mechanical hemostasis doesn't always work. You can still get bleeding from under the clips, particularly if there's partial closure. And we need also to talk about clip closure techniques. And this is a new area of research that needs much more study. We have the concept of partial murial closure, bringing the mucosa together and then full thickness serosa to serosa apposition, which is what you see here. And that's what you really need to aim for in perforation, but also absolutely in perforation, but also to prevent post-EMR bleeding. You can close most of these defects. This is mucosal apposition, three different examples, which is more so dragging the mucosa over the top. If you do that, then you can reinforce the base to get serosa to serosa apposition. With mucosal apposition, often the thing will spring apart. But if you do something like this, 13 clips, you can close it. But the problem is, as the defect gets bigger, so if the radius of the polyp is three centimeters, you've got 28 square centimeters to close. You just can't close that. Look what happens. Look how diminutive the clips are, looking at this huge defect. But even partial closure works somewhat, because it probably reduces the shearing forces in the right column. Just a reminder that clips do create clip artifacts, so be prepared, not you should clip, but be prepared to interrogate clip artifact, which has the same pit pattern as the surrounding mucosa, just the pits are a little bit more dilated. Don't mistake it for recurrence. If you're worried about it, just cold snare it off. So if you go along and you see some bumps in a scar, cold snare them off. Putting it all together, this is a lesion over the ileocecal valve. This is the last video. We finished the resection. We've got a big defect here. There's the fat of the valve. Don't let that worry you. Snare tip, aspirate gas, move gently, keep moving. Now we've completed the snare tip, very aggressive with the snare tip, and now clip closure, aspirate gas, get the tissue to bounce up into the clip, start on the same side as the fluid, so the stem doesn't fall across the wound, aspirate gas, and bring the tissue together, and even this big defect, we can more or less close completely, and things are going to get better and better in the space anyway. And that's the end result. Final slide, if we just go advance. Yeah, so all of these things, very important, and of course I want to acknowledge the great team that work with at Westmead. Thank you.

snare resection technique

endoscopic mucosal resection

thermal ablation

Sydney Deep Mural Classification System

closure techniques