I'd like to call up a large polyp resection colonoscopy all stars, the podium, Michael Bork, Westmead Hospital, University of Sydney, and here comes Tanya Kaltenbach, UCSF VA Health System and Raj Goswami, representing the hometown, Northwestern Memorial Hospital. Okay, let's see if we can get this to the slide. Okay, so we're going to talk about challenging resections. We saw a lot about creating cushions in the earlier section, so we're going to talk about, in the first case, contemplating assessing vessels and surface patterns and margins using various techniques, then conceiving of a resection strategy, and a little bit about the tips for completing the resection. So we'll start with a couple of little cases for our panel, and we'll start with this video. There we go. Okay, so we come across this polyp, and we'll have our panel look closely at it. We're looking at it at white light, and we're looking now closely and near focus or magnification up at these sections that are there, and we're going to use underwater, which will give us some extra magnification. And so we're looking at the surface pattern, and we're using what's in black is looking at the vessel pattern. And so we're looking at the various areas, and we're seeing what looks like a tubular villus adenoma. We don't see anything with more advanced vessels. We're also going to be looking at the imaging when we're starting to do an injection around the periphery, and we're seeing we're pulling back the scleral needle as we move away with the dynamic injection, another version which we saw earlier with Dr. Satickno in the earlier session. So we're looking at that, and we can see very nicely in blue the normal pit pattern of the periphery, so we can see our margins quite well. And let's see, we're going to also then we're going to look at this and assess it very well by looking at this is a left colon very large lesion here in the rectum. We're looking at turnaround, and so we're going to pause that for a second now. Well, actually it gives away what we did. So I was going to ask Michael if you could comment, and how much do you rely upon the imaging and the vessels and that sort of thing in terms of choosing your resection strategy in an LST? Yeah, exclusively really. So we don't, so we have to sample the polyps by imaging. Imaging is everything, and biopsy is like an historical throwback which only gives us a small portion of the polyp. I never look at the histology of any polyp that's referred to us. I just look at the polyp and I can tell what it is. So this is a granular lesion. It's a 2a plus 1s. It's mostly flat, but there's a dominant nodule. We need to know where in the colon it is because that also stratifies the risk for invasive disease within the dominant nodule, and we did previously show that in flat lesions the detection of cancer is very accurate. Sensitivity is 95 percent in flat lesions. So I like to use the pizza and the calzone analogy. You know you know what's on a pizza, right? Because you're just looking, you know, you can tell there's pepperoni, whatever, and the calzone, you don't know what's in the middle, right? So if there's a nodule, you need to use the data that has been established based on location, size of the nodule, whether the lesion's granular or non-granular, how many nodules there are to decide whether there might be what we call covert cancer. So Raj, you're going to talk about the evidence a little bit, but so looking at this lesion, it was felt to be granular. It was in the rectum, and you can see we decided not to do ESD, but what would you have chosen here? I think, you know, I'm an EMR aficionado, but in this lesion in the rectum with this dominant nodule that's, you know, bigger than a centimeter, I think this is one of the cases where ESD would have made sense up front rather than EMR, just because of that risk of cancer when you have that dominant nodule that size in an erectile lesion. Okay, so let's continue the video. You can rewind it. We can switch to ESD if you want to. Well, you could have done, but we decided to do basically the same concept that we were concerned about this nodule and decided to do a hybrid, so a full thickness, and you'll just see in a second the pathology of that dominant nodule in a second that did show a high-grade dysplasia, and you can see, Michael, it was right in the rectum. Okay, so we'll go on to the next case. So this is a patient that was referred from an outside gastroenterologist who took a polyp off, again, in the left colon and thought there might be some more left behind, and first look, there was a little bit more left behind, but there was more to it. I kind of call this the iceberg effect because, you know, using close-up imaging and with optical contrast, you can really look around and see, you know, a really big area there, so despite the prior work, it was able to be lifted. So, you know, Raj, what about margin imaging? What do you do to image your margins? You know, tips from art you want to give? I think, obviously, the audience well knows, but, you know, many practicing gastroenterologists don't use near focus at all, which is, you know, important in training to just teach people that near focus exists, NBI exists, and then using a cap to really get up against the margins and look at it. This is clearly someone probably who just missed a large proportion of polyp. This is not a small recurrence. This is probably just residual polyp that wasn't seen, and so, you know, just like you said, looking very closely, and I think the injection when you're removing a polyp that's very flat with that dye can really help you assess the margins well as in addition to NBI or the near focus or an optical imaging in near focus. So, Tanya, would you ever, do you ever, when do you use chromo and actual, actual chromo? Well, I think in this case, if you take a step back, you can appreciate it from a long view with white light, right? There's an interruption in the vascular pattern. Your eye goes to where that scar is, but then you look around and the vascular pattern stops. So, it's just like the tools we use to detect lesion. You can see that there was this flat behind it. So, you start with the long view, and then you go in to give you confidence in the borders, and at that time, then you can turn to NBI and see the borders. You could then do near focus. If there is any depression area, I think chromoendoscopy is very helpful in those cases, but here, I think you could see it with the, these tools with the white light and NBI. So, let's hold that thought and look at the next little clip, because we're going to talk about borders again in an SSL. So, we can get this to the next slide. There we go. Next slide. Here we go. And let's run this one. Okay. So, this is just one, this is a, there's a, there's a clear cap, cure mucus cap, and it's actually involving two folds. And so, in this case, you know, we really see the border best by, you know, with an injection. So, I wanted to comment on whether or not, you know, you're, whether you're injecting with the methylene blue or injection, are you, what are you doing in terms of margins with SSPs? Yeah, I mean, I think you definitely can see here that that blue hue contrast gives you that border contrast a little more after you inject. A lot of times with the serrated lesions too, they're, they're redundant a little bit, right? And so, you can follow the board around, but once you inject, you can see the difference, the distinction between the slightly raised and then the normal mucosa. Right. And you can see the normal pits get, they get magnified and separated as you, as you, as you inject. And then, I mean, then the last, after you resect these, I'm sure you think you'll show, but looking at the defect is a skill in and of itself, right? Looking at your defect and following it around the periphery and many times there you can see a residual or not, but to be able to target it up front is always better. Does this influence you in your, when you're doing a EMR and a large SSL, does it influence you with a concern about some, some expressive injecting this thing and having it flatten out completely to make it hard to resect? I find the SSL is the easiest to inject. Personally, I think they lift up nicely even without as much maneuvering. I don't know if that's the other people's experience. I think it's especially though, if you inject into the lesion. So that's where the looking, I do, I've seen people inject around the lesion and it sort of gets a little bit more buried. So this is one where I find it easier to inject into the lesion and liberate it. It looks like you're going to do hot EMR, right? Are you going to do hot EMR? Yes. We don't need to. We're going to come, we're going to come to that. 100%, you mustn't. Guys, everyone, serrated lesions, cold. Yes, you do. But we're going to, we're going to come to that in a little bit. Yeah. Oh, all the data's out. Yes. We've been, we've been debating hot and cold and we're going to come back to that a little bit in later case. Let's get the next slide, please. I didn't realize I wasn't sitting with friends. We're friends. Next slide. Yeah, this one. Okay. So we're coming across this lesion is a left colon lesion that's occupying much of the lumen. And, but, but assessment has looked, there was no, the, there were no particularly worrisome vessels or areas of, as Dr. Sotekno called earlier, bald areas to suggest cancer. But there's a little bit of a problem of this lesion at being a little bit bulkier trying to go and, and grab from, from left to right and to, to do a nice resection. So, so in terms of a strategy in this, this lesion we're going through and we're going to take out the sort of the first piece and sort of, it doesn't really slip, but it looks like it's slipping, but you really are getting on the left side. And then we're going to go and grab a second piece, but it's becoming increasingly difficult to kind of go from left to right in this one. Can we pause this? Let's pause this. So anyone in the panel want to comment, Michael, you want to comment, what are you going to, what are you going to do here? Are you afraid about shaving off the top of this thing to get down? And I don't like to do that because I think it, it makes things messy and you often get, you know, bleeding from the cut surface. So the most important thing, first of all, is to set the lesion up in the right way. So make sure the fluid pool is opposite the lesion. So you're maximizing the effect of gravity and often the morphology, the apparent morphology, the lesion will change quite a lot. If you rotate the patient, you probably already rotated the patient. This is the best position we can get. Then what I like to do is, is follow the, the normal mucosa into the base of the lesion. And we call this EMR dissection, if we were going to do it by EMR. So you often find an area where you can make an excision, expose the submucosal plane, and you can follow it towards the nodule. And then, and then, you know, continuing that way. So often inject, you can even inject parallel into that area as if you were doing a submucosal injection in an ESD. Yeah. Try not to, and, you know, depending on the, you've got to estimate the footprint of the polyp, you know, if it's broadly attached, if it's not so broadly attached, you might be able to remove it on block. Yeah. Tanya, are you going to do this in a, you, you counter this on a screening colonoscopy, this lesion. Are you going to, to, to do this in the, in the, in the ASC setting, or are you going to bring it to the hospital? Are you going to biopsy this thing? Are you just going to bring them back? What are you going to do with this thing? If you're encountering this without really having discussed with a patient? I mean, I, the discussion I have with patients upfront is if I find something, I remove it. And we talk about some of those risks. I think I don't practice in an ASC, so I can't answer the sort of resource utilization and time constraints as much there. But if I saw this at this time, most of my patients, I would do that at this time, but I recognize that the resource constraints. And if your staff isn't equipped and such, you may want to bring this patient back. I would not biopsy it. And the patients who get referred similar to what was said they understand that a photo is, is what we are looking for. Not necessarily a biopsy. If I thought there was cancer in it, then that's a different story, right? If there's deep submucosal invasion or things, then you would biopsy it. But in this particular case, I would remove it. And if I didn't have the time, then fine, you can schedule the patient again. Right. Well, this was, this was, this was referred and I definitely would not, you know, entertain doing this in an ASC with, with, with 30 minute slots where there's any pressure whatsoever on time. And you haven't really talked to the patient in detail about the, for, you know, the added risks. So I'll just show you, I, Michael, I didn't, you know, like the idea about it, but I, I, I did, can we advance the video again, please? There we go. So I did at that, at that point, just take this piece off. You can see right here, we're actually deciding to take a hunk off the top of it. And then it made it quite easy to get and then complete the, the resection moving over. But you saw that there was that area on the left side that you could easily have injected more. We're going to come back to this polyp in a little bit. But right now we're going to, we're going to turn to a, for Tanya to take over and let's, in this presentation and let Tanya come in and give us a little video-based talk on some resection strategy more in detail.

challenging resections

polyp removal

colonoscopies

resection strategy

imaging