from my right, or closest to me here, is Michael Kaminski from Poland. Michael, welcome. Amrita, you've seen multiple times already. So, Michael Burke from Australia. Michael, welcome. And Monica, and our ASG president, Doug Rex. So, you can see a star cast here. So, we'll start with our live cases. So, if we have Dr. Rappicci and his team in Milan at 10 p.m. on a Sunday, let's see if we can stream them in. So, Lyle, if they're there, let's go ahead and get started. So, Alessandro, good evening. Buona sera. How are you? Please, great to see you. You've probably heard the panelists who are here. So, thanks again very much to you and the entire team in Milano for being on a Sunday night with us. Please, go ahead. Good afternoon, everybody. Thanks, Pradeep. Thanks to ASG for asking us to be part of the postgraduate course. Of course, super glad to have Lyle from Milano, and also thanks to other course co-directors, Amrita and Monica. The panelists are super good, so I'm glad to show this case. Probably the slide can go on. This is a 52-year-old female patient that's been discovered because of family history of colorectal cancer. It's been referred to us because of a flat lesion over the right colon. Description of the lesion wasn't very clear, so we prepared it. We are already in the right colon. But before we move forward with the procedure, let me thank the entire team here. It's late evening. It's been a great team effort. I'm so glad that all the nurses, technicians, physicians, fellows, they all supported this live broadcast. I'm so proud of having all of them next to me, working with me tonight. I'm using a Fujifilm latest generation scope, so I think you can get the endoscopy picture now. Okay, good. We already reached the right colon. Let me show you. Of course, when we do colonoscopy, patients, they all do a split bowel prep. For today, it wasn't easy because it was late evening, so we did the same day. All the time, for all our patients, we do AI-assisted colonoscopy. In this case, it was with a GI genius from Medtronic. I'm reaching this segment, trying to understand where the lesion is. Let me have a look. This is the heliocical bulb. Here, the GI genius is telling me there is something wrong, a multiple site. Let me get closer and closer. You see, we can start recognizing a lesion, which has a sort of a yellowish color, white and distinct margin. Despite the fact that the GI genius is helping me identify the lesion, it's telling me this is a precancerous lesion. You see, now it's going bigger. As much as I get closer, I have more indication. We are using a zoom scope, so we have the possibility of enhancing the view of the lesion. Now, I'm switching to LCI and even better to BLI. Based on peak pattern and macroscopic appearance, this is typically a flat lesion type 2A with a typical pattern of serrated lesion. I don't know if the panelists do have any comment on this, but the appearance looks extremely clear. There is a very distinct margin. When I go here, I can see how big is the lesion. It's probably about 2.5 or 3 centimeters, which again, to BLI, to have a better representation of the borders. Again, here is a lesion and here is a lesion. This is a typical ghost lesion that can be easily missed during colonoscopy. You can see now how big it is. The pattern is very typical, I would say. There are future suggestive serrated sessile adenoma. It's difficult to say whether or not there is also a dysplastic component. I know that there is a microboard into the panel, so probably Mike can add a comment on this. Thanks, Ali. Great to see you. It's a typical flat serrated lesion. I don't think there's any obvious dysplasia. Usually, the dysplasia presents as a demarcated area within the flat lesion. You can typically identify it. It also tends to be nodular. It's important. It's a very important point because if it is a serrated lesion with dysplasia, you want to make sure that you resect the dysplastic focus on block in a single piece. But I suppose you're going to do this by cold snare excision. Yeah, great point. I want to know also if the other panelists, they do agree that there is a non-dysplastic features and based on that, if we can progress to resection. Ali, this is Doug. I definitely agree. So when you say 2A, you're talking about the Paris classification, right? In terms of the shape. And then the nice classification, this would be type 1. So it looks like a sessile serrated lesion. And like Michael, I also don't see anything that looks dysplastic. I am interested. I'm not quite sure where the appendiceal orifice is. Would you show that to us? It's not involved, I would say, with the lesion. Very good point. Very good point. I do believe that the orifice is right here, probably. It's not completely involved, but at least the rim of the lesion is on top of that. Okay, good. I'm just asking, if it was going down and you couldn't expose the entire circumference, what would you do? If the whole thing was not clear of the appendiceal orifice, how would your approach change? So it depends. Normally, even though there is involvement of the appendix, we keep going with the cold resection. We leave the appendix as the last part. Just if we see that we cannot go inside, we cannot resect after injection. We may use a full thickness resection, but this is a very unusual situation. In general, we should be able also with involvement of appendix to be quite radical using the injection. And of course, when there is involvement of the appendix, you can use the cap and suck a little bit of the tissue inside using the cold. Just try to resect as much as possible. But just with regard to the border, I think it's important to inject now because injection is very helpful in delineating the border. So we normally use LAV, which is the long lasting solution approved in the United States. And the beauty of using a long lasting solution is that you inject once and afterwards you can keep going with your resection. So what I do, I first push the needle very deep down and afterwards, I know this is too deep, I pull back a little bit to try to stay into the submucosal space. And when I feel that I'm a little bit more superficial, I inject. You see? And the easy injection, just moving the scalp back and forth. Okay, inject. So Michael, can I ask you, would you inject this because you've reported removing big lesions like this, serrated lesions without injection. And we saw a recent study that showed follow-up, you know, even removing without injection. What would you do right now? Yeah, we tend to inject them when they're larger than two to three centimeters because you get a lot of intraprocedural bleeding. And so we use dilute adrenaline or epinephrine, one in a hundred thousand. So it minimizes the bleeding. We know that intraprocedural bleeding is a risk factor for recurrence because you can't follow where the residual tissue is. The other advantage of, so I don't think you need to inject small lesions because it's sort of overdoing things. You can just go really quickly, but larger lesions, it's helpful also because you get quite a firm cushion. So it's very helpful to push down on the cushion. And Michael, also, if I may say, helpful to delineate the borders of the lesion. Sometimes they are very indistinct. When it's such a big lesion, it's much better to have a delineation inject. Yeah, I sort of, I like to inject too, and I would probably inject this, but you know, as this literature appears and then, you know, we hear more and more about all the plastic waste, you know, we got to get an injection catheter out. We got to get the fluid out. It adds to the cost. And if people are showing that they can do it without, and they accurately resect them without recurrence, I think there's an argument for it. Yeah. Okay. Ale, could you tell us, because you started injecting from, I mean, far away from the appendixial orifice, what would be your approach? Would you like to start close to the appendix or far away? No, I started injecting from the, what I call the oral side of the lesion to see how it's going, the injection. I followed the rim of injection. I'm not concerned too much about orifice, appendix orifice here. I feel that we can remove this without getting trouble with the appendix. Normally we do this with a 10 millimeter cold snail. This is the captivator. And it's very important how you get started. So the first, when you start, it's really important because it may create the right path to keep going with the resection. So very few tricks. I remove as much as possible haze and I start adding a little bit of water. So it's not completely underwater, but some water just create the condition of making the tissue a little bit more floppy, open. It's not popping. Please change the snail. Okay. Quickly. Sorry about this. Okay. So I want to ask about the fluid because, you know, Michael, you just said you like to have the fluid be firm, but these serrated lesions, they just separate so easily from the submucosa. And sometimes you can get a fluid that's almost too firm. Like you want to, you want to have a little bit of laxity so you can push in and make sure you're cutting through the submucosa. I wonder sometimes if just saline is not good enough for, for these. We just use Silon anyway. Oh, you do? We don't use a lifting solution, a special lifting solution. Oh, so you do use saline. You don't use a special lifting suit? Yeah. Yeah. Oh, okay. Yeah. I'm not, no, no, we wouldn't. I mean, to remove this, actually, we don't use a special lifting solution for anything. Oh, you don't? No, not even for ESD. Okay. So you use saline for everything. We use just gel effusion, but it's similar to saline. I actually like kind of a viscous solution for adenomas, but for serrated lesions, I think saline works well and you want that cushion to be a little bit softer. Yeah. Okay. We, we started with the resection. Normally the first piece, I try to have a little cuff of normal mucosa. And once that's with the lesion, I count one, two, three, and move to resection. Okay. Okay. That's very important. So you definitely need normal tissue at the margin. So I say to the fellows, we go half and half, the half, the snare should have near plastic tissue and the other half should have, you know, normal tissue at the margin. So Ali, I saw that on your first cut there, you, you had a small cord of, of submucosal tissue. Can I ask, do you try to avoid that at all? Does it make any difference? Do you worry about it? Can that harm any residual polyp? No, no, I don't think it's really relevant. It's been described by Mike that is a truly submucosal tissue. So I don't care too much. I'm going a little bit larger on the margins to avoid recurrence. Close. Yeah. So the larger the piece you resect, the more likely you get a cord snare protrusion. And that's just bunched up muscular mucosa because the plane of resection is, is really in the mucosa just above the muscular mucosa. That's why there's no bleeding because you're not injuring submucosal vessels. So we know from several lines of evidence that it's, you know, the chance that you'll have submucosa in a cold snare resection is, is less than a couple of percent. And, and so, cause I hear some experts in cold resection say that they try to avoid snare stall. They maybe sort of adjust the size of the piece though. They're not taking quite as big a piece, so it doesn't stall. And so you don't get that cord. You don't have to pull through. Do you think that makes any difference? I don't, I think for the most part, it doesn't matter. It particularly doesn't matter in serrated lesions because we know that the recurrence rate is, is about one to 2% in that big study we've published in gut. So, so for serrated lesions it doesn't matter. I think for adenomas it's different because, you know, the tissue is much thicker. So perhaps with serrated lesions, you can go as large as you'd like, as long as you're using a 10 millimeter snare. I think the upper limit with adenomas is around seven or eight millimeter. Once you get up towards having the snare completely full of tissue, it's hard to cut through. So actually Ali, it's Amrita here. Can you tell us a little bit about the type of snare you're using and the size? Yeah, thank you Amrita. So nice to hear from you. And we are using cold snare, dedicated cold snare. This is the Captivedo. And I don't need to get a big amount of tissue. It's going step by step. And I think that when you do cold, you have to use all the time dedicated snare. Ali, it looks like you have some adrenaline in your injection fluid. Okay. No, I didn't. I just use the LAV and nothing else. I don't use too much adrenaline because our anesthesiologists, they don't like too much. But just in case, when we have additional risk of bleeding, we may use that. Of course, there are no data showing that adrenaline is better than non-adrenaline solutions. I agree that sometimes can be helpful for cold resection to reduce the amount of intraprocedural bleeding. But you can see here, the amount of intraprocedural bleeding, again, is very low. Typically, it's a minimally serrated lesion. So if you get stuck with a cold snaring, you can try to further straighten the catheter of a snare and then it will more easily cut through. So if you get stuck, you just ask your nurse to straighten the catheter and it will go through more easily. So this is a very, very good tip. But even so, how often would you agitate against the end of the scope if you do that? Hardly ever. Hardly ever. Can you talk about the progression that you're going across that polyp in terms of your sites of resection? So I would say loving the expert comments because they are allowing me to progress without being too much busy in talking and close, close, close. And that's been great. Having Doug and Michael and Kaminsky also talking, they are super experts. I'm very respectful of their opinion. So they allowed me. Here's a transaction against the scope. Yeah. This is sometimes when you get a little bit stuck, you can just pull and go against the scope, but open. I want to care now about this border. It's important that I remove all the fluids now. So I think it's important that just like you make sure that you get a lot of normal tissue in the initial bite, that you are ensuring that there's no bridging polyp by getting the edge within the submucosa as you progress along. That was beautiful. So what is interesting that I see more and more experts adopting cold, but when we receive medical reports from community hospital, I see the uptake of cold is going slowly. So I think we need to invest in terms of education more on the safety and also the relatively easy technique of cold because sometimes I think it's underused in a context where there is not a big expert doing this. So it's important that everybody knows that below 10 millimeter ultrasound polyp can be easily removed at the risk of having delayed bleeding. It's very, very low and there are data showing that also with patients under anticoagulants, still the risk of going in trouble with a cold resection is very minimal. Close. So Ali, we know with adenomas from Michael's work with snare tip soft coag that the recurrences probably come in from the margin. What do you think about that for serrated lesions? I mean, you cut this out with a wide mark. The one thing about cold snaring is it does not cut as deeply as hot snaring does. Michael, do you have any thoughts about that when they recurred? Is it possible that we're just not cutting deeply enough and we can't see it? I think recurrence from cold is probably not from the margin, but also from within the center of the lesion as well because sometimes we don't have overlapping excision. And if there's a lot of bleeding, say with an adenoma, the serrated lesions don't bleed very much at all. But with an adenoma, if there's a lot of bleeding, it can be very hard to follow. That's why I like to use the dilute adrenaline. If this was an adenoma, this would take twice as long and it'd be much more difficult. So we find in a referral center that a lot of serrated lesions like this have been biopsied by the referring doctor. And you can often actually see the exact biopsy site. This one looked like it really came out nicely, but I mean, do people have thoughts about that? We try to encourage people, if you see a serrated lesion, you don't want to remove it, which is at this point, this technique is so easy that I think anybody could do it, but don't biopsy it to avoid that. So may I ask the expert to follow just for 30 seconds the evaluation of the borders and make suggestions to me if you believe there is any residual tissue to be removed. I'm trying to go all around the lesion here. I have a little bit of pulling of liquids so it's not easy. I turn the scope differently. So also the other important point from time standpoint. In the center there, there's just rotate just there. See that? Yeah, yeah. So I do suggest, yeah, I do suggest cold ablution for that rather with... You could just take the snare and chop it off again. That's your cold snare protrusion. Okay, we will do like Mike suggested. I think that's where you amputated against the scope, that little piece there in the center. Yeah, here. You mean this one, no? Yeah, that little guy right in the middle now. I think that margin delineation is really crucial in here because some first reports reported on high recurrence rates for serrated lesions, but later reports, they tend to, I mean, lower it down toward the, let's say, adenoma prevalence of recurrence of adenomas. Therefore, it was probably like, let's say, misdelineation of lesions. Yeah. Yeah. So, HICO's study, the CARE study, really showed that serrated lesions were the ones at high risk for residual, for recurrence. Yeah. So, I think it's a failure of imaging, of accurate imaging that we perhaps don't fully resect. But they were using standard resolution scopes, too. And I mean, I do think, you know, the pits, and I think when you go back and look at them in follow-up, you know, you need a, you need very good resolution, because the pits, the retained serrated pits, if they are there, they can be very subtle. Yeah. And also, at the margin, you know, there's often a lot of, particularly with diathermy. So, you can't really tell if there's residual adenoma or residual, you know, serrated tissue or not. It becomes challenging. So, Mike, you happy with this? I think there is still a tiny, tiny part of a serrated lesion here, just into the center, I will use. Yeah, it's almost like, if you look at, in the overview, you can see that there's almost like incomplete mucosal layer excision in the center of the lesion. You see a mucosal pattern. So, there's some retained lamina propria there in the middle. Impossible. Perhaps all the epithelium is gone, but there could still be some residual epithelial elements where you did the amputation. So, I would just take the snare and cut that area again, chop, chop, chop. And actually, in practice, we tend to make, we tend to make the defect about one and a half times the size of the polyp. So, even though your margin looks fine, I would, I mean, personally, I would just like go around the whole thing and chop it all out again. But it takes no time, and you can do it so quickly. So, we just get... So, at that point, you're just having fun. No, not really. No, I'm just... It's just recreational. No, no, we're trying to, well, because we know it doesn't add any risk to the patient. Like, it doesn't matter how big, you could take out the whole cecum here, there's no risk to the patient. But my thought would be, if this is going to... Because I thought that edge looked really clean when Ali was looking at it, that if it's going to recur, it's going to recur from the base. Yeah, from the center. Yeah. So, you're going to recut some of that submucosa, huh? Or whatever that, whatever plane that is. Looks like submucosa to me. To me, it looks submucosa. I'm just interrogating this. Yeah, around there, I think, just there, there's some... I would just push down and then take that tissue, but maybe there's no epithelium left. But when we first looked, there was, there did seem to be a couple of abnormal pits. Ali, can I ask you, you used the water jet a lot during the procedure to flood the area. And, you know, what do you view that as the role? Are you just trying to get clean? Or are you trying to actually fill, put some fluid into the submucosa? Like, add your... I think both, so it's important fluids to have a water jet to clean, but also to have additional submucosa elevation. So, I think Mike should be a little bit more happy now. No, no, we're all impressed. We're all happy. polyposis did you see on the way in there are a lot of little polyps around the place yeah so and in fact a lot of them do like so when you see and also your data showed that when you have a single advanced lesion two centimeter or greater 20% of patients have another lesion that has high grade dysplasia or is larger than 10 millimeter you beat us to that study we were trying to do at the same time that you published it but it's the only time I've ever beaten you to anything but so it's very important that the patient so the pathway for these patients is usually index procedure and then resection procedure and at either of those two procedures the the metachronous the synchronous lesions are often not detected particularly if the if the index lesion is very dominant if it's a huge lesion that takes a lot of time then you won't see a lot of the other little adenomas that are around the place so I think as good as we are at reducing recurrence almost all of these patients need another colonoscopy within 12 months or at 12 months because you know 20% of them are going to have a significant another significant polyp and probably 30 to 50 percent of them maybe 50% will have at least another adenoma yeah this is I think really crucial so we should bear in mind that these patients also are at increased risk of advanced adenomas so I mean you should look also for adenomas as well yeah while we're waiting Michael you have you know a lot of data also about treating the edges of polyps that you put out there this in this case we see very clearly negative margins it seems to be a benefit of you know particularly with this cold cold snare technique when are you practicing that yeah yeah so so I think the serrated lesions don't need to have the margin treated because the risk of recurrence is really low because there's such you know and they peel off so quickly but it's just the adenomas Ali we're back with you or is that your twin is that your twin in the other room was this you now it's me to me to me Justin next to the other room so I love the discussion six months one year three months six months I think it depends on the local policy and I read that the slowly growing but also I think that earlier is the identification of potential recurrence of batteries for the general overall management of the patients so we back into another patient's 77 year old with the sun comorbidities that we discover that we found these relatively small lesion into the right column the problem is that is a very looping column it's unstable the position and you think this is just beyond the fold that would be nice to have this in a retroflex position but it's difficult to retroflex I'm trying to use the cap to display entirely the lesion so my general evaluation about course I'm very cautious with so many experts it's a granular type and when I go to the BLI so either the machine and myself we do believe it this is the Noma you see the heat map you can see the map yes and telling us it's a the Noma so now the problem here is with with a resection because I'm a very unstable in a very looping position with my scope so I'm telescoping a little bit I do not have a one-to-one control and this may be an issue so I would like to start from this side and afterwards progress slowly to the other side because my feeling is if I start injecting here I will reverse the lesion and my approach to the lesion will be much more difficult so I'll try to turn the scope put the lesion at six o'clock and then we start the injection and this time we are injecting Oriza gel so this is another approved gel so Karina is ready to go with injection so differently from previous injection I will inject the step by step and I will not inject the entire lesion because I will inject and cut and afterwards I will repeat injection and cutting again of course this potentially could be doable also with the cold but I feel more confident here using a hot resection so middle out again go deep pull back a little bit and start injection. So Ale there are some suggestions that endocav may help us to stabilize the scope would you use it in some situations or not? Yeah but you need to know that the lesion was in this specific situation I didn't know in advance I'm not sure that endocav can stabilize your position rather there are scopes like the G-scope from Fujifilm or other scopes that can help with stabilizing I think it's another one two stop I think it's a matter of remaining stable with the scope don't play too much my movements are very minimal I just exposed and elevated the most distal part the sacral part and I will start the section with a 15 millimeter dedicated snare so I don't think we have to over elevate these lesions specifically either because of the position and also because of the size so if I tend to over elevate I create an elevated flat lesion so I do not have the polypoly the effect I want to get when I inject the lesion so of course we can observe the lesion more carefully now. This is Ale what you demonstrate is very important so with these lesions in the transverse colon particularly if the position is unstable and then you've got the respiratory movement of the diaphragm it's very important you see that those are learning these procedures they follow the respiratory movement with the scope actually the scope has got to stay still because the respiratory movement is always going to be there so you just have to stay in the best position and not follow the inspiration expiration movements. Ale why a 15 millimeter snare? Because I learned from you Doug all the time you suggested in all DDW courses here in Milano during imaging you don't need the biggest snares so we know it's a granular type lesion we do not have any suspicion of invasive histology advanced histology so there is no need to get big bites and risk adverse event is that correct? Well it seems like when we use bigger snares and get great big pieces of tissue that that there's just a little bit greater chance of of catching muscle especially in the transverse because it's intraperitoneal so yeah so I do think that when sometimes when these things are have a certain bulk to them you know then you know a 15 millimeter snare can be a problem so I don't have a strict rule about it but I think for a relatively flat lesion like this it's a it's a pretty good rule to follow that be a little less greedy and a little more careful and you'll cut the muscle less often. Okay let's inject again. And has anyone on the panel had experience with the the overtube that helps with scope stabilization the Pathfinder? I mean I've used the Pathfinder for really really redundant colons to get to the to the cecum and I do think it's a very nice overtube and but I tend to for EMR most of the time it's straightforward enough that I just it seems like another device that isn't isn't necessary but what about you Emerita have you used it at all for this? I've used it for unstable ESDs and then and as you said extremely redundant colons for completion. Inject. Okay we are repeating injection. Yeah the other tip I'd make for the audience is if you could retroflex it of course makes your position very stable particularly when the lesion is on the proximal side of the fold and you can do that in the transverse you can go down to the cecum retro in the cecum and then and then just come back slowly you have to come back very slowly go around the hepatic flexure and then or often you can retro in the in the proximal transverse because there tends to be a big space where the hepatic flexure is so just because you can't retroflex right where the lesion is you can often retroflex further in and then come back slowly and it often makes things very simple. Yeah also more redundant is the column more looping sometimes more difficulties using these these overcube devices so sometimes rather than helping maybe also creating more challenges. Of course I think Emerita is super right when she says about ESD if you need to do ESD you need something that helps in keeping the scope very stable but in this specific case probably since we are doing standard EMR we may skip this step. So you know now the lesion is fully elevated open open fully I try to get some help from the normal tissue here to accommodate my snare I suck a little bit into the cup okay like this and now close close close okay very gently. So Ali you're using electrocautery here with this particular lesion would it have been fair to do a cold EMR would you be critical of someone of doing a cold EMR in this lesion? Yeah very good point Doug I think the tissue is too thick and the snare that we have they are not good enough to tackle with this thick tissue so not sure we're ready with the present devices probably in the future with different devices we may progress to cold also with this kind of lesion we do not see any bulky area open up so of course it's important that you try to be very precise like here little inject little sucking sucking close close close we are using the bio tree herbic generation with the endocard 2 setting 2 and let me display this and probably we need to do the last residual part here you see how much important is the cap in this situation we have an RCT randomized trial going on with cold versus hot and this would be a lesion I would feel comfortable going either way with you know you have you have the choice when you get in in if there's bulk or any concern about advanced histology you know you would probably use electrocautery but the flatter granular lesions I think are fair game we have the same we have the same study going this study would this lesion would have been randomized versus cold yeah but the cold is going to have a warm recurrence yeah yeah we can already tell that so in my practice if I one of the things I would actually go by sometimes is the size the bigger it is I always consider it can I close this defect you know so if it's going three quarters the way around the right colon and it's you know granular and flat there's no way you can close it or no way I can close it then I'm more likely to take that out cold and just accept the recurrence because the recurrences are not that hard to deal with it's so easy and then you get you get the patient through the initial procedure without a risk of bleeding and something we don't talk about a lot is specimen retrieval in this case he's delineated nicely there aren't any particularly suspicious areas but if you had a nodular lesion you know with one or two areas anything you would do differently with regards to either the approach how many pieces you resected in and or thinking about your retrieval yeah so this this lesion is 100 percent benign there's zero chance it has cancer in it that's a flat to a granular lesion we know from huge data but if it had a dominant nodule then the risk in the right colon um you know maybe it's like two to three percent so you the snare's got to close really slowly there um so that was a problem there but what about a smaller snare here Michael yeah or the other option you can do early you can do suction pseudopolyp if you if you say we're going cold no no why don't you suck that tissue into the channel suck it right into the channel now and then you can chop it off the residual also good boy yeah yeah let me try away there because you can turn it into its own polyp um so yeah if there's a dominant nodule we take that area out in one big piece the risk of cancer and that's also very low but then we submit it ex vivo when we retrieve all the specimens we separate them and we submit the big piece separately okay open and we pin it i think also there yeah maybe there's no residual so the difference in the snares the this the this snare is 0.3 millimeter wire diameter whereas the normal uh emr snare that he was using is 0.4 so that's why it bites in and you can see the technique of pushing down very firmly he also changed the orientation so i think that helped helped yeah a lot okay let me look to the base you see yes you're going to finish up here so if you can um yeah okay tell us your assessment and what your plan will be okay so my plan is just to remove this part cold and the acid part here very quickly and afterwards since the patient say has multiple comorbidities is taking anticoagulants open open open i will deliver pura stuff on top of this to create a safe submucosa protection michael would you the cast technique here yeah you could do either or you could just re-excise i think i only like to do casts when we have to i much prefer to excise everything like he's doing yeah so ali and um unfortunately we've run out of time i want to thank you so much again for staying open uh opening your unit to us and sharing this beautiful demonstrations of um apolipectomies we'll leave you now and continue on with the rest of our program thanks okay thank you guys

endoscopic mucosal resection

EMR

colon

Dr. Alessandro Repici

Milan

Fujifilm

GI Genius

Medtronic