Welcome to ASG Endo Hangouts for GI Fellows. These webinars feature expert physicians in their field, and I'm very excited for today's presentation. The American Society for Gastrointestinal Endoscopy appreciates your participation in tonight's event on polypectomy techniques. 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. 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 as part of your registration. Now, it is my pleasure to introduce our GI Fellow moderator, Faris Ayyub, who is an Advanced Endoscopy Fellow at Baylor College of Medicine. I will now hand over this presentation to Faris. Thank you, Marilyn. Hi, everybody. I'm very excited to be here and have, I'm seeing a lot of fellows tuning in, so we're very excited to do this. I want to introduce our panel. First of all is Dr. Mohamed Othman. He is the William T. Butler Endowed Chair for Distinguished Faculty and Professor of Medicine at the Section of Gastroenterology and Hepatology at Baylor College of Medicine. He's also the Chief of GI at Baylor St. Luke's Medical Center. He has more than 100 publications and book chapters in the field in both pancreatic ovulary disorders and advanced endoscopy. Dr. Othman has ongoing research and grant funding focused on clinical trials in the field of third space endoscopy, endoscopic submucosal dissection, and pancreatic ovulary disorders. He's also the Senior Associate Editor of GIE, and he's also the founder of the Texas Interventional Endoscopy Group. And he is my own personal mentor, and I'm very happy to have him here. Next up is Dr. Salman Jawed. He's a Therapeutic Endoscopist and Assistant Professor of Medicine at Baylor College of Medicine. He has an interest in third space endoscopy and endoscopic submucosal dissection. Dr. Jawed is an invited lecturer at several national courses on third space endoscopy and leads investigator-initiated trials in the space. He also has a particular interest in fellow education, which is very relevant, and has created a dedicated hands-on endoscopy curriculum for general GI fellows at our program. Last but not least, Dr. Tara Kihanyan is a Therapeutic Endoscopist and Assistant Professor of Medicine at Baylor College of Medicine. She also has an interest in third space endoscopy. Dr. Kihanyan completed her Advanced Endoscopy Fellowship at Baylor College of Medicine with a focus on third space endoscopy and her General GI Fellowship at the University of Miami. She's an active clinical investigator, and her work has been published in prestigious journals, including Gastrointestinal Endoscopy and Gastroenterology. And after all these fancy introductions, I just want to say I know the three panelists personally. They're my mentors, teachers, and colleagues, and this is going to be a really nice session. I want to encourage the fellows to please, please ask questions. We want this to be interactive. Put them in the Q&A. I promise I'll get to them as soon as possible, and we all agree that we want this to be very interactive. And that's it for me. I'll hand this off to Dr. Offman, and we're very excited for this. Thank you, Ferris. So I'll start sharing my screen. So that's a really beautiful introduction for everyone, and I think Ferris is stressing that he wanted to be interactive. We'll do our best. So we'll start first with our disclosure for the three of us. So before we start talking about the opaqueness techniques, I felt like we should have a little bit of discussion of what you do when you see a polyp. And we'll start here with Dr. Jawaid. In the scopic inspection, forget about all these fancy classification that I myself forget them sometimes. We do them for the studies, and we have to hang them, and I don't remember them. You look at the polyp. What are you really looking for? What are you looking for when you look at a polyp? Yeah, I mean, I look at basically what's my first instinct. And so those instincts are, first of all, size. You know, what am I getting myself into? Size tells me how much time it'll take to remove this, and if I can remove it, if I'm a general endoscopist. And then I kind of look at overall, just overall structure of the polyp. You know, are there, and you can talk about the Paris classification, which we're seeing here, but is it pedunculated? Is it sessile? Is it flat? Is it depressed? Are there ulcers? Kind of general things. And I think, you know, regardless of the classification scheme, I think these things kind of make sense as you look at a polyp. And you see that it's not just this normal, regular pattern, but there's something more irregular about it. And so that's the first thing I would look at if I'm a, just the first time looking at a polyp, assessing overall morphology. We can get into the specific pit patterns and all this, but really kind of looking at overall morphology, size, and, you know, then deciding on what to do with it. Yeah, I feel, I agree because size, you know, tell us exactly, like we know if I'm doing a screening colonoscopy, and then you end up with three centimeter polyp, even if you are an advanced endoscopist, I don't think it's a good idea to remove the polyp in that session. Correct. And I feel like a lot of us make this mistake because they know what they are doing. They decide that, well, I would just, in part, be removing it. Then it takes longer than usual. People knock on the door, telling you, next case is here, hurry up. And then you do this service to this patient and to the other one. I do not do a lot of screening colonoscopy, but when I do one, I tell my patients that there is a 5% chance that your polyp will be larger than two centimeter. And if it is, I'm not going to remove it today, upfront. And I tell them, we are from the 95% of the people who can remove their polyps within the same session. Yeah. Another thing, yeah, go ahead. I have a question for you, actually, Dr. Othman. You said the screening colon, a lot of GI fellows. So the size definitely matters for polyps, like there are smaller. Is there any certain number of polyps you would leave in the setting for the screening colonoscopy? I know you have your fast ones, but something not as fast as that. So the size really makes us say, okay, this is large, I'm not going to do it now. But then when it comes to this annoying 15, 20 centimeter tiny small polyps, that's when it gets challenging. That's when I feel I'm obligated to remove as many as I can, especially now we are doing cold snare. What do you think about the breast lesion, Tara? Well, I mean, the breast lesion, I guess, like I'm sure that you will cover all the classification. The more depressed the way that the morphology looks like based on which classification you look at, the chance of maybe the emolument of the submucosa and the method that you're going to be removing it will matter. So not necessarily the size, definitely. And also, as Dr. Dorade mentioned, the morphology and how it looks like or is depressed, the pit pattern, the combination together, give us an estimate of what are the chances if you don't cut this polyp from the deep, like there'll be a good submucosal, like risk of submucosal invasion is higher or lower. That's what I think. Yeah. So I want to highlight for all the fellows here, this one you see is depressed 2C. This is what we call the heaped up mucosa. That is a war thing. That's cancer. So just get used to look at this and know that this is cancer. By the way, that image is taken from the Multi-Society Task Force for Managing Polyps. This was published in AGA, ACG and ASGA. The three societies came together. It's an amazing paper. I think each fellow should read it. We should not remove these depressed fellows here. I agree with what Tara said. Yes. Before we go on, there's for the fellows, you know, we're going to go into all the criterias, but there is a semi-validated simple score. And it's really like logistically kind of what we do all the time. But it's I believe it involves a size. It's called an SMSA score, size, morphology, site and access. Because basically what you want to know when you're like a gastroenterologist is when you're attacking these polyps, you know, how much time do I have? Basically, the reason why you don't attempt these, as Dr. Hoffman alluded to, is because you want to have a good outcome, right? You want to have a good resection, a good complete resection, right? So you want to give yourself time. So they've looked at this and have validated this briefly that like an SMA score, I think of level three, which I think is like over nine or ten points, will tell you that this is likely not going to be a complete resection. So you should avoid this and reschedule for another day or send it to a more experienced provider. And I think it's basically size up to four is like the highest size. And it's graded by points. You can look it up. Morphology, which is pedunculitis, SIL or flat, and then site, left or right, and then access, easy or difficult. So I think this is a quick, easy way for a gastroenterologist just doing a screening colon to be like, hey, look, should I attempt this or not? Along with the other features that you're going to talk about. Yes. Ferris, what happens if you remove a polyp that's cancer like this depressed one here? Yeah, I think you will not be able to get the polyp on block or get it completely. And so your pathology, if you get it in one piece, the pathologist will tell you your margins are positive. And now the patient has to go to surgery. It's a big problem. I wanted to ask the panel while everybody's focusing on the depressed lesions. And as a fellow, I found this challenging sometimes. I would tell my attending and say, hey, you know, I think this is a depressed lesion. I'm very concerned. And then my attending would come and say, well, you know what? I think this is a pseudodepression. It's not a true depression. And so how do you guys maybe give us some tips and tricks on how do you really tell a depressed lesion that is likely high grade dysplasia or cancer from a pseudodepression among a kind of lifted area? That's a great question. And I will let the panels. But I want to just get quickly what happens if you remove a depressed lesion like the one you see here? Because if we go out of this session that our great fellows do not remove this one, because I will tell you when I was naive and I removed polyps like that, that's when you get a perforation. This stuff is so stuck. They're taking all the wall. You're going to put your snare around it and you're going to have a nice big hole. And a patient with cancer, you might spread the cancer. So I'm coming from the future. I'm telling you, don't get excited and do that. Do not do it. All right. So I feel that pseudodepression is one of the things I get a lot of refills saying non-lifting lesion. Actually, they lift very fine. So sometimes he got mucosa. If you can see the buckering, if you can see the muscle layer and the tension between the fold, that's really tells you there's cancer. But if you have a big lesion between two folds, it's normal to have a depressed area. And sometimes even if you try to inject it, it wouldn't inject very well. But if maybe if you go around it, you can inject. But also prior biopsy can cause fibrosis and an injection. So I agree with you, Faris, not every depression is cancer. I would let Salman and Tara talk about that. Yeah, I also think exactly that you have to know what has previously been done to the polyp. Now, if you're doing a screening colon, you know, then it's different. But this is where I think PIP patterns and kind of looking at under magnified light and narrowband imaging or eye scan can sometimes help. It may still be difficult to differentiate biopsy from kind of avascular areas. But, you know, you learn these kind of things when you talk about the NICE and the J-NET classification. This is a time where you can really look at that depressed area. And I feel I can get a pretty educated guess as to what's going on underneath. So that's what I would suggest. All right. OK, so we'll move right now to my favorite classification, Dr. Kahani and Tara. If you don't tell me, Tara, what do you think about this classification, lateral spreading bulb, LSD? I personally like it more than the Paris classification. What do you think, Tara? I think it's more easier for the first clue to take a look at it, to remember. You know, it took me a while, like a few months, when I started my fellowship to remember the classification. I mean, a few weeks maybe. So exactly not to actually like exactly what to do, what not to do. But it's granular and non-granular. It's going to give like a first impression to me. Like, what am I going to get myself into? So the first thing when I see, OK, it's granular, non-granular, that's going to make a difference for me. And then I will look at the size. I mean, I'm sure that later on that we'll cover, but after a certain size, if they're granular, non-granular, it will impact my decision. Then I will go to other classification. I agree with you. This is like an easy first look at how it looks like. Yeah. So I feel like your happy friend is number one here. It's like it's granular, always large, but easy to remove, easy to raise. That's what each and every one of us feels happy about. And you can see here the granularity is uniform, right? They're good. That's the one that you will do and go home feels great and you'll be able to remove it. That number B here is actually, you would be tempted to do it, but there's a difference between A and B. And the difference is that the granules here are different size, right? So that's the one that you will also be able to do. You'll feel great. You'll go home happy that you did this large polyp, but one week later, you're going to get pathology saying early adenocarcinoma or maybe high-grade dysplasia foci, and you wonder what was going on. Then C and D. C, you have to be really so good in doing it. D, this is a non-granular lateral spreading. Know this image. All right. It is not the breast yet. This is not the breast lesion that we saw in breast specification that has D submucosal cancer. That's thinking of becoming a breast lesion, but not yet. It is almost heaped up here, but flat surface. You don't see this nice, beautiful granules. You can see smooth surface. That polyp, you still can remove it by endoscopy, but you want to do ESD. So this is another visual image to remember. That's number D here. When you see it, no matter how small it is, you want to do ESD, and the guidelines would say around two centimeters or larger, you remove it by ESD. If you look here at submucosal invasion, Salman, what's your experience with this type of polyps and risk of submucosal invasion? Yeah, I think it's actually accurate. When you look at C and D, especially D, I would bet there's at least some superficial submucosal invasion. I mean, anecdotally, I think it's almost always pans out that way, unless it's been extensively worked on before. I think that's one caveat to that. Yeah. So there was a recent study about the rectum specifically. When you get, like you can see here, polyp in the rectum, and it's in retroflexion. Honestly, any rectal lesion that large, if they have mixed granular, which is granules that has variable size, the recommendation now for this, do not do EMR, do ESD. Are you aware of these studies coming recently, or do you think that's really something we should be doing? ESD, granular polyps in the rectum that have mixed granularity. Yeah, I mean, I think rectal lesions are, out of all the areas in the colon, have the highest risk of submucosal invasion, even with granularity. So I do agree, A, to get those patients who do have cancer, to allow them to have, you know, potentially cured of resection. And B, rectum can be easy, but a lot of times it approaches the dentate line, or close to the dentate line. And so there's a high risk of just recurrence in general, if you try to remove this any other way. So I do agree, I think for rectal lesions, especially over over 20 millimeters, regardless of granularity, I probably would favor ESD. Faris, do you have questions for the panel? Yeah, we have one question from the audience. It's a very good question, actually, is when do you actually use this classification? At what size of polyp do you start talking about LSDs and granular versus non-granular? Dara, you want to answer that? Well, I guess you briefly mentioned two centimeter, one centimeter is a granular or non-granular naturalness spreading. And based on the size of it that you see, then you will decide. Two centimeter and one centimeter will be your cut-up. Something to remember. Yeah, I think I use two centimeters usually. Me too. Because smaller than that, I would just use the word sessile. I think I use the word sessile. I have a question for all the panelists. I know that in our center, we do a lot of ESDs, but for somebody like they're doing like more screening, more like that level of EMR, what type of this classification do you usually recommend, at least even if you're sending to a referring provider to just have a habit to use it in their computer-assisted document? Honestly, to me, I feel that it doesn't matter what classification you use, as long as you use the word depressed, flat, non-depressed, ulcerated, granular, non-granular. I feel like if you use this term, regardless of what classification, it will be helpful. To me, in my notes, I hold myself to a higher standard that I have to because we do studies and I have to put the classification. However, if somebody told me, I see a depressed lesion, which is ulcerated, I would right away think about deep submucosal invasion. If he say, I have a granular polyps that span over two folds, I would know right away that that's a granular LSD. So I feel like if the people just use the term without the classification, that would be fine, as long as they know what they're looking for. Another question from the audience, and you may go over this during your talk. They're asking, like, what would you actually do for the pictures A through D? How would you tackle those lesions? That's a great question. A, EMR. B, possible EMR, but be careful. C and D, ESD. And D might even have early cancer, so D is questionable depending on size. But definitely, number one, A, that's a favorable for EMR. And the reason is granular lesion will have really very small risks, 3.2% risk of submucosal invasion. And for that reason, in most of the areas of the colon, it will be fine to do EMR for these lesions. And then one last question before we move on. I guess this is a very important part of the talk is, does this classification apply to pedunculated lesions? Yeah, it doesn't. It's only for societal lesions. Yes, that brings up an interesting question. You know, a lot of times when you see pedunculated lesions, the top part of the polyp often looks quite scary, if you will. Like a lot of, if you look at the pit pattern, and I don't think it works the same way. My experience is that it's very hard to tell. Now, you can sometimes tell if there's going to be at least high-grade dysplasia, given the vessel pattern and the surface pattern, but it can be quite challenging. So if you see a pedunculated polyp that just doesn't look, you know, it doesn't have the characteristic coliform appearance on the top, I'd be reluctant to kind of remove that in that setting, maybe kind of reevaluate. That's another. Yes, and then one final question. I guess this is very relevant and good for the type of talk is, what do you, do you biopsy these lesions, particularly the depressed ones, or do you leave it, just describe it and leave it to the advanced endoscopist? I know the group will have a lot of thoughts. I'll mention something briefly. Just yesterday in the journal Endoscopy, there was a study by Michael Burke and his group in Australia, and they looked at how all of these polyps that were biopsied, whether biopsying it really yielded any new information that can help management, and the answer was no. And in their study, it showed that it actually made resection a little harder. Now there is some mixed data. When I was a fellow at the University of Chicago presented data that the biopsy, if it was very superficial, maybe to the edge or in a heaped up area, doesn't really make a difference, but be interested to hear what the panel would do or what would recommend for the fellows. So I feel like if you have a depressed lesion, you should biopsy where the depression is, because you know that that would be cancer, and if you notice cancer, you will do a different workup to begin with. So we have to remember that adenocarcinoma in the colon indicate invasion of submucosa. Mucosal lesion on the colon, they are not adenocarcinoma. We call them intramucosal adenoma, and we got away from using that word, and we're doing high-grade dysplasia. Understanding that is very important in the United States, because in Barrett esophagus, we can have mucosal adenocarcinoma, but when it comes to the colon, there's nothing called mucosal adenocarcinoma. It's a high-grade dysplasia. So once you biopsy a depressed area, and it comes back on the biopsies adenocarcinoma, this means that you have submucosal invasion, and the question is how deep it is in submucosa. Now you're going to do a CT scan, a BIT scan, if it is closer to the rectum, maybe EUS and MRI before you embark on doing ESD, because if this is beyond the upper third of the submucosa in terms of invasion, I would send this patient straight to surgery. And the reason here why you send it for surgery, because if it's submucosal or go to the muscle layer, although you can remove it by endoscopy, even by full thickness resection, we do not have a way yet to remove the lymph node. So we have to remember this as our limitation. Yeah, I would ask the question, anything in endoscopy, there has to be a purpose for it, right? So in A, if you see the picture A, biopsying, what is it going to tell you? It's going to tell you tubular adenoma. So it's not going to change your management, right? But D, you wouldn't know. If there's adenocarcinoma, like Dr. Hoffman said, that's going to change my management potential. It's going to make me do more workup, right? And then the most important thing, which he mentioned over and over again, I want to highlight is that when you biopsy these ulcerated or depressed areas, focus on, don't get the rest of the polyp, focus on that area. That's going to be the highest yield, because what will happen is a lot of times they'll send you a depressed lesion, but they biopsied just randomly in the polyp, and you don't get the full answer. So that's what I would highlight. Yeah, so for Norman, I would say, yes, when you see depressed area, biopsy it. It will give you more information, but do not over biopsy it. One biopsy would be enough. A question that was removed was saying, why you remove lesion C by ESD? Well, actually, the person, he's right, there's an area of debate. People can do EMR, or you can do ESD, but you should know that in non-granular lesion, the rest of submucosal invasion is 15%, which means that in lesion C, if you remove 10 lesions like that, you're going to be fine 8 out of 10, and you did a great job. But you might get one or two patients that they have adenocarcinoma, and you might need to send them for surgery. So yes, it is in the border between EMR and ESD lesion C. However, I would say it's safer to do ESD. Still, if you don't have the skills, you can do EMR after discussing with patient. If they come back cancer, you would go for surgery. Dr. Hoffman, while we're on the topic of identifying polyps and deciding when to refer or not to refer, good question about how do you tattoo, when do you tattoo, where do you tattoo, I think all very relevant for fellows who may want to send these out to somebody with more experience. So what does the panel think? Maybe Dr. Kehanian can tell us what she thinks. Actually, I'm going to, I think it's still this point from Dr. Hoffman, this is something that I learned from him, because originally when you see the polyp, like you see a tattoo proximal, tattoo distal, it depends on that after a while you come and see and the tattoo is going completely under the bed of the polyp. And especially when you're removing it, not necessarily with EMR also can cause a scar tissue and granulation tissue and during ESD it's going to cause fibrosis as well. So Dr. Hoffman was always saying that, remember, if you tattoo like very proximal, it's actually like dripping, it will come, if you tattoo very close to the lesion, it will actually come to the lesion as well. So make sure that you're not in the very close proximity, use the opposite wall, at least like in describing you're actually tattooing. Just tattooed wouldn't help the future and possibly some polyps are very flat, it's hard, they're between folds, sometimes they're going inside a diverticulum or something. So you explain like tattooed two folds proximal, two folds like distal or the opposite wall. It's very important to actually come to like a description. For some polyps that are pretty obvious, like for example, the one that if you're not removing number A or number B, or even number like D, that it's possible that you are in certain locations that are easy for endoscopies to see like rectum or sacrum. So really tattooing or that area wouldn't really help for anatomical landmarks. So it's a middle of transverse colon or like middle of descending colon, yes, definitely perceive it tattooed, but polyp is not obvious. Yes, I agree. I totally agree, Tara. I feel like, and we published that in GIE, somebody, Michael Berg, I think, and I commented on it. They show how when you inject the tattoo initially, it looks even nice in a perfect location, proximal to the region and the proximal site. It just keep migrating to go to be under the polyp. And that exactly, as Tara was saying, what came to my mind is that why are we going to do tattoo like we tattoo for surgery? If you're going to send for advanced endoscopies, tattoo two folds beyond the lesion. So towards the oral side. So if you are in the colon and you inject, usually the injection go towards the oral side. So I usually do that. And the other thing I would say, for God's sake, please do not do that. Do not mix the tattoo with saline and raise the polyp with it. Some people do this for polypectomies and really they remove half of the polyp and then they leave the other half. And then when you go back to remove this polyps, all the muscle layer became like fibrotic now. So I don't know who really started that pattern of using tattoo as a raising agent or injection agent. We should avoid doing that. It should only be used for marking, not as a lifting agent to remove polyps. Salman, anything? No, 100% agree with all that. I agree entirely when I reiterate documenting, you know, ipsilateral, you know, the contralateral side. Very important to do that and focus on the opposite side. If you do the opposite side, even if you're close, I mean, ideally don't be close, but if you, you know, the opposite side will prevent it from migrating. All right. So I think Ferris is typing the answer. There's a nice question about what's your conduct in residual agents after ASD? Adenoma, hybrid dysplasia, or intramucosal adenocarcinoma in the rectum. Salman, you do ASD and you have a residual adenoma. Sorry, what was the question? What do you do with it? Yes, like you hope when you do ASD that there's no residual, right? Yeah. What if you have a residual for one reason or another? Yeah, I mean, either in the rectum, I mean, either you can repeat ASD, which is going to be challenging, but doable, or it depends how much residual tissue you have left. You're talking about at the follow-up or are we talking about at the index? It's mostly like follow-up after that. And I agree with you. So salvage ASD has been proven to work very well. Right. Yes. What if you make a saline bleb first and tattoo? Now that decreases the chance of spreading. So what's happening is even like, it is okay to do the saline bleb, that's fine. But what's happening is that the leaves, like ink, is very irritant. And now it is in the submucosa above the muscle layer, it still will cause irritation no matter what. So you just want to be a little bit proximal to it, far away from the ink. We have another question about injection solution. We're going to go later for that. We have a part about that. So I'm going to move quickly because honestly we are really behind time. Do you really want to talk about the GNET? Should we just jump? I think we should move on. I think you should move. Or can I just say one more? I don't want to move without them. Okay, I just want to say a few things to my dear fellows. Number one, always use NBI at GE Junction. No matter what, make it a daily habit in every EGD you are doing. Number two, always NBI your polyps and see the results back. Any polyps you remove, if you want to learn to use NBI or any of these things, please follow up and use it every time. And then remember that the brain is a normal adenoma. When the brain gets a little bit wider, it is adenoma trying to become high-grade dysplasia. When you lose everything, that's when there's cancer. In your practice, you're going to see type 1 and 2A all the time, which is the white dots you can see here. That's iverblastic, that's adenoma. If you can really learn this two better to begin with, this will help you so much. I think we can stop here for that. All right. So some people recommend biopsying the largest nodule in the granulatory spleen just to know. So going back to this discussion about toolbox for tissue resection, and I want every one of us, no matter how you are, where you practice, you are an endoscopist, you are a surgeon now, you have to know your devices. You cannot just look around to your technician to teach you, right? You are the captain. People will look at you for guidance. For pulvectomies, what you are seeing right now is your toolbox. You need an electrosurgical unit, you have injection devices, resection devices like snares, hemostasis devices, ablation devices, traction devices sometimes, that's for ESD more, closure devices or tissue opposition devices, and a stabilization devices. I would like you to remember this slide. This is contain anything you're going to do for any tissue resection. And if you look at all the development that happened in the world of tissue resection for EMR-ESD, it is basically one of these. So let's go right now and talk about electrosurgical unit. Salman, can you give us a brief introduction? Yeah. Blue, yellow, what's going on? Yeah. So you can get as detailed as you want with this and it can get really complicated. So let's, you know, I would just think of, think of this simply, you know, and we'll make it very straightforward, right? You have the whole point of taking a polyp out are two things, right? We're trying to remove the tissue and we're trying to prevent bleeding. Those are just your basic principles, right? And so that's what this whole, when you see the effect, interval, duration, all these numbers that you see that mean nothing to felt, most fellows or even endoscopists in general, that's what all that is, is tinkering with. Okay. So bottom line, you end up looking at that, I'll go into this in more detail. You have cold snare. So when we say cold snare, it's a snare, specifically snare, but the point is there's no electrocautery, right? There's no grounding. It's purely just cutting of the tissue just by sheer force from the snare, right? So there's no coagulation properties. There's no thermal injury. So it's just cutting of the tissue and you may have bleeding. And that's obviously one of the side effects. When we talk about hot snare, right? You're basically cutting the tissue with electrocautery. And along that, it's also coagulating to prevent bleeding. Very simply, when you talk about hot snare and the settings, understand that when we talk about effect, effect is basically just the intensity of the coagulation, right? How much coagulation is occurring. So that's the effect. The higher the effect, the higher the power of the coagulation. So each cycle of a snare, you know, if you hear attendings, they push the pedal, right? Some push it all the way down. Some put the yellow pedal. We're talking about the yellow pedal, which is the cut current. The cut current is basically a blended current and it's one cycle, right? So you push the pedal, the yellow pedal down once, the full cycle goes, dun, dun. It's a full cycle, all right? That involves cutting and coagulating. So the tissue is cutting, the snare is cutting and it's coagulating at different intervals. And so that's why we change the intervals and duration. So the interval is the time between each cutting coagulation cycle. Whereas a duration is the duration of the cutting cycle. So if you want a long cut, you want to cut more tissue. You want to go faster, right? You increase the duration. What that's going to do is that you're going to cut more, but you're going to bleed. You can have potential for bleeding, right? Because a coagulation phase has not kicked in. But if you want more coagulation, then you're going to increase your interval time. So if you have a pedunculated polyp, for instance, and you want to prevent bleeding, you want a little cut. So you're going to make your duration of cut very small. So you put your duration low, but you want to put your interval higher because you want that coagulation phase to stay longer. And so that's what the whole cycle is. It's cut, coagulation, next cycle, cut, coagulation. And so all this is changing that. It's important to know that because wherever you go, you're going to have different kinds of settings, people play around with it. So it is complicated and it can get complicated, but just simply know that what these three numbers, three variables do, and then you can kind of play around with it. So, yeah, and I agree. You know, there's the studies about cutting versus coag, like pure cut, like forced cut, which is the blue barrel. And then the yellow one, which you have endocut INQ. And honestly, the study showed no difference. And I know everybody called that study, but these are small polyps, less than one centimeter. Once you get to the much bigger polyps, something like three, four centimeters that you're doing piecemeal AMR, then really you have, in my opinion, endocut. And endocut, as Salman was saying, it is just cut and coagulation together in one interval. Endocut, by the way, is a brand name if you're using every machine. If you're using Olympus machine, it will be called pulse cut. If you're using ConMED machine, it will have another name similar to endocut. What's the name, Salman, for the ConMED machine for the- Well, they just say G. Yeah, it's called G cut. So basically the idea is that you don't want to just use pure cut. You want to use cut with coagulation. And when you introduce the coagulation or the cut, you have two ways of introducing it. You either introduce the two currents running together, which is coagulation and cutting together. And if you do that, that's called dry cut. It's just continuous cut with some coagulation to it. Or you can make a circle, which is coagulation-cutting, coagulation-cutting. And that's when you hear your machine have these two beeps and the two sounds. And if you are so good, you're going to teach your technician to only cut when your machine is cutting. So your snare is cooking. It goes like that, tin, tin. And in that tin, that's when you close and cut a little bit. Tin, tin, you cut again. Tin, tin, you cut the third time. Dr. Raju, and he is our professor. He's in MD Anderson. When I was a fellow, I would listen to him, what Dr. Raju would do. He would do the cut himself. He got used to listen to the endo-cut, and he would cut himself and teach his technician, everybody, that you have to listen to the sound and only cut when you hear that cut. So liver cell man spoke about right now, effect intervals, duration. That's very important. We have to think about it. You see here is an example of what we call crispy, clean cut. So how crispy, clean cut will happen? If you use enough cut with enough coagulation, enough cut to be clean and coagulation just to prevent bleeding without having this too much white issue. You know, I see a lot of these pelvic tummies on Twitter and everything looks too much white. That's not good. You want to have this beautiful, crispy, clean cut. The less coagulation you have, the better it is. All right. I think that would be good on this. You know, what you usually use for coag. Tara, you want to talk a little bit about soft coagulation? Yeah, so I have actually a question. I think we're going to cover the soft coagulation. I wanted to see what the panel would be. You know, sometimes, like, especially maybe in the stomach area and the gastric area, sometimes, like, we've been training, use your blue pedal felts and then yellow pedal. So can you just, like, maybe somebody like Dr. Ahmed, can you explain that part? What was that? Is it something you recommend for chronic quality too? Sorry, I have some issue with coag. Yeah. Yeah. You want to say something? Yeah. Oh, yeah. So I don't think there's, you know, it's very good. The teaching is, and I think that's why I got used to this, is when, you know, these vessels, especially in the stomach or pedunculated polyps in the colon, the teaching is, obviously, you don't want to cut straight through there, right? Those are big, big vessels. So you want to have some degree of coagulation. And so the thought, the rational thought was, if you use the blue pedal, which is only coagulation, that maybe it'll just coagulate the vessel, okay? And then you can go back to your yellow pedal, which has both cut and coagulation, a blended current. So I go back and forth with it. I've done the coagulation first, just because it, honestly, because it feels like it works. It has, I haven't had a problem like that. I don't know, Mohamed, do you just go straight to the yellow pedal and just put more coagulation or increase your interval? Sometimes I can use a coagulation of a big blood vessel. If I feel so worried, I would do coagulation more. But I feel right now, the message to them, the less coagulation, the better. We should be using actually even cold snare for any polyps less than one centimeter. And maybe even there's data. You want to share this data, Salman, for what's a cold snare? Yeah, so when you look at cold snare polypectomy and then cold snare EMR, which are two different things, but cold snare polypectomy has been shown, at least for polyps less than 15 millimeters. I think that's key. Less than 15 millimeters overall to be a better option than hot snare polypectomy by all standards. I think once you go over 15 millimeters, the data says that the rate of on-block resection, even over 12 millimeters, the rate of on-block resection is actually lower in cold snare polypectomy. So know that anything less than 15 is better off probably cold snare. But when you get over 15 with cold snare, you have good outcomes in terms of less delayed bleeding and perforation and post-electrocaudary syndrome, but you may not get the polyp on block. All right, so we'll move to injection agents. I just want to send a message about one of the agents that were in the market that has been injected for a long time, or for the last three years, Origel, which just was grown from the market recently. The reason is it was causing extensive foreign body granuloma in the submucosa. When people would come back to look at the endoscopy, you will see a mass like lesion, think that there is a recurrence. This patient would be sent for surgery, and a lot of these patients end up having unnecessary surgery. So this patient, this market, this now agent is removed from the market in December, but be careful. There is a lot of lesion was injected with it that you might still, for the next two to three years, see them when you're doing endoscopy, and you'll have to be careful about it. I think it is time now, and I don't know, Tara, you're still with us, right? Yes, yes, I have some issue with the computer, so with the video, but I'm still here, sorry. Yeah, so the question would be, and we had it, what's your favorite injection agent? And I'll ask Tara and Salman, what do you guys do? Well, I think in our center, we usually use the Hespan solution, which is, based on our experience, actually is a methanol gluten and saline, and actually works pretty well. And we repeat colonoscopy. If we do need to repeat, like to do ESC afterwards, you don't see that much of a granulation tissue, a scar tissue at the site, if you need to intervene upon a lesion or something, that actually works pretty well. I mean, sometimes when I'm doing like EMR, and it's not really like an ESC day, we don't have the solution mix, we have to also consider like what we're doing. Sometimes we use like other paper solution in syringes, we have a variety of like samples, and they also usually work well. I personally don't have the habit of actually injecting saline to lift. I know it's something that I heard before, and I've seen people doing. If you really know that the concept of dynamic injection, when you're injecting, I think it's actually better and safer, because at some point also over-injection can be like against you, and you can actually like completely flatten the polyp, it's not gonna be ideal for removal, but then it's gonna make your life even harder. Yeah, I agree with Tara. So I, for just regular polyps, I just doing colonoscopy, EMR, simple like 20 millimeters or less, I always choose a saline. And this goes actually back, if you first go back to what Mohamed was talking about, polyp selection, you're not sure what to do, and you have some time to remove polyp, but you're not sure if it's lifting. If you're going to embark on lifting, if you are, focus on using saline first, because that has a less detriment to the polyp if you decide to bail, if you will, rather than just using methylene blue with another inject solution. So use saline, see how it goes, and then you can proceed. Now with regular polyps, I will often just use saline for what Tara alluded to, is I can always take the inject, it doesn't last very long, which is fine, because if it doesn't last long, I just do it again. But if I mess up also, then it doesn't last long. So I can redirect my injection agent, and I can always go to something stronger, if you will. So I prefer to use saline as a first go-to, not during ESD, because I want a long lift, but just simple EMR. I go saline first with methylene blue, and then if not, then I use other agents. Yeah, but I feel also it depends on your practice and what's going on. So if you have four cases of ESD that day, you know you're going to use, you're going to get a big bag of Xpand and repair it with methylene blue. Don't forget that methylene blue by itself is $150. So once, if you cannot use it for one patient, you're going to get four bags, open the methylene blue and inject in four bags. That's acceptable in terms of cost, and there's no contamination or anything. However, let's say right now, I am doing a screening colonoscopy, and I end up with two centimeter lesion. I personally don't like, and I know a lot of people like saline. I personally don't like it. I like always to have a color. And in this situation, I'm not going to tell, hey, please go get me methylene blue. The nurse look with other one. Where is the methylene blue? Let's open it here. We can find methylene blue. Let's go to the other room. I would rather have something remade. You can just inject it right away, and you can have a safe removal for lesion two centimeter or higher. Less than one and a half centimeter, I agree with you guys. Is this overkill to use a lifting agent? Yeah, I think so. So I agree with you. I was going to ask you, yeah, so you kind of lose this, but do you always like a colored solution? I mean, you technically don't need it all the time. Actually, you don't need it. You just need a lift. Yeah, that's true. But if you have two centimeter, yeah, if you left, it all depends if you're worried about, like you can see perforation better. And honestly, it could be one of the meth. I just got trained to use methylene blue or endocarbonate for everything. And maybe saline would have been exact same thing. And honestly, some people, yes, they use that. I actually do more and more just like just saline. And we're going to show videos of underwater EMR, maybe even without injection. The underwater, you start to see that even without injection and you're doing the same thing. So go a little bit next to this resection devices, snares. Your favorite snare, Tara and Salman, quickly because we're behind time. Well, I mean, we have different types of the snare. We will see like we have like hexagonal, we have regular based on the size of the polyps. I mean, really depends on when you're doing coldest snare or hottest snare. And you want to use like a more stiffest snare if you're using like the type of like you're doing, you want to remove end block or you're using hottest snare. And like the size of the polyps should correlate the size of the snare. If you have a 10 millimeter polyp, you go with a 20 millimeter snare. There's a chance that at the end, when you're closing it, it's gonna slip over. It's just gonna remove the remaining part of it aside to the lesion. So it's very good to have an area of margin. You have to remember if you have a 10 millimeter polyp, you want to have an area of safety that your snare actually removed a little bit of normal tissue around the polyp as well. So for a 10 millimeter lesion, you go with a 10 millimeter snare, probably your margin may remain causative. So give yourself the area of like an error for the size of the polyp that you want to use. So I'm gonna corner you a little bit, Tara. If I give you a size of snare to choose, five, 10, 15, 20, 25, 27, 35, what's your favorite? 15. You have only one. 15. 15. What about you? As a general, if I want to do like a... Polypectomy or EMR? Well, for EMR, you will only have one snare to do everything. Yeah, I like 20. Maybe because I'm used to doing big polyps. That's why. But 15 is fine too. I mean, 20, I would go to 20. Yeah. I like 20. Any advice about what snare you would use from your point of view? I mean, I like the braided snare for a lot of these flat polyps. But yeah, I mean, what Tara said. I mean, everything is different. Each snare has its own pros and cons. And because I know how many polyps we remove, like what we order in our unit, I would tell you order 15 millimeter snare all the time. So actually, if you have one snare, you want to put in your unit that can work for smaller polyps and large polyps, it would be 15 millimeter. So I add advice to our fellows because the more confident you'll get, you'll embark on removing large polyps and you'll find a lesion that three centimeter and you decided to use 35 centimeter snare, please do not do that. You're going to take the polyp with the fold and the muscle layer and you're going to have a nice, beautiful target sign and you're going to take a picture of it, but still patient will be admitted and be in pain. So don't do that. I honestly, 15 to 20, 20 is the maximum snare you should use. And that's actually from evolving. I used to use 35 snare and then I start to say 25 is my max. Now I don't use anything more than two centimeter if I'm going to do piecemeal and I'm going to show you some of these videos quickly. So Dr. Osman, I wanted to ask you, I know this is kind of a little behind, but I think this is very relevant. Do you mind sharing with the fellows just some basic concepts about snare design? I mean, I'm sure we have some very advanced fellows, but also some early fellows. Yeah, I think we can quickly go. Yes. And like the grading of the snare. Yeah. So I think this, one of these video here will illustrate that. And that's, I think it's from Salman, right? That's a video. Not this one. The next one is. Not this one, okay. So one of that, so that, you know, there's two types of snare. One that I call them flimsy. They are not like graded. They are very easy. These are the one that you can use them for ERCP to bulls 10 and things like that. Or if you are doing cold snare, and then you will have the one for the EMR and for flat lesion, and this one are graded. And the graded one will have a tip on them. And this tip is designed for anchor. Can see here we are putting this polyp and it start to, by injection, even open up. That's the tip of the snare here. I injected enough to able to be able to make a cut. And then you can see how the snare is really graded and it's really strong. And in spite of the polyp here being very flat, you would be able to remove this nicely in one piece with a lot of normal tissue around it. 2007, when I was in fellowship, my attending was teaching me only take the polyp, do not take any normal tissue around it. Now we are teaching our field the opposite. Actually try to take more normal tissue around the polyp because that's what make a difference. So that's show here. That's the tip of the snare. You can see that little bit circle here is just what anchor there. And there's another graded snare. I think this is Salman's case, right? Yeah, this is my case. Can you talk about it a little bit? Dr. Jowade and also just comment to the fellows that this is a little bit of an advanced technique, not extremely dangerous, but typically you would try to tip that design tip of the snare and anchor it on the mucosa without cutting. So you guys are taking it to the next level and actually cutting into the mucosa to anchor the snare tip. So Dr. Jowade probably highlight some of that. Right. And one thing I realized, you know, that snare tip is actually quite, it's made, most of these tips are actually made to kind of bury into that mucosa and kind of get that without causing problems. So if you notice how Mohammed and I will do when these guys have watched us, you know, we're pretty aggressive with how much force we put because they can really kind of anchor you there. So you really got to find an anchoring point. That's one of the key steps of good polypectomy, good anchoring, or else you just slide right over it. So this just allows us to have an anchoring, a better anchor, because the tip of the snare is like stuck in that submucosa and allows you just to anchor rather than just flop around. So that's the technique here. We just inject a little bit above the lesion, a generous injection. So you have cushion, put your snare tip in, just one or two pops of the yellow petal. You pop in, ideally you can just stay there, open your snare, and you try to do it right over the center of the lesion, and then just drape your snare over the polyp. Yeah. So we have a comment here from Enoch. I want to comment on what he said. He's talking about how when you inject with a coloring agent, you can see the polyp better. And that's totally true for sessile serrated adenoma. A lot of time, you cannot know the border of sessile serrated adenoma without injecting enough. However, I was believing in that until Enoch, I don't know if I'm pronouncing your name correct. I'm sorry. But I would tell you, I was believer in that till I start seeing underwater EMR. And I will tell you, you would be surprised that in underwater EMR, you can tell the margins much better and as good as when you inject the methylene blue. And these videos here, you can see, you'll see some examples of underwater EMR. I think we should go through them since we are talking about snare design and technique. And Tara, tell me more about your experience with underwater EMR. That is true, actually. Underwater EMR, it's actually helpful, especially that like this lesion. Sometimes the lesion, I know that I personally got used to like lifting the lesion and like trying to remove it with a cut snare or poly snare. But in certain situation, depends on how the polyp looks like, even for 10 or 15 millimeter polyp, this underwater EMR can really help you to achieve unblocked with no heat effect. And you can actually go with a minimum heat effect if you want to do like hot snare, but then the cold snare, we've done like so many cases, even this week. And it's very quick and it's safe and gives you the clean margin of polyp. Yeah, so something happens when you put the water, the mucosa goes up, the muscle relax and go far away. This is one of the Salman videos too here. Yeah. Salman, don't you think that underwater doesn't work if you have a lot of stool? I mean, it does. So this is why underwater EMR, I love underwater EMR. I think studies have shown more and more the superiority, but it is a learning curve, right? Because like, how do you see underwater when there's stool and this kind of... And so I find that there's a little bit of stool there. You can still do it, but obviously the more stool there is, the harder it becomes. You'll have to flush more of the saline through, right? So that's why it takes longer. I would recommend actually either marking it. If you have some stool, mark the lesion. You can even inject a little bit just so you have an idea of where the polyp is. Like in this case, I had just injected a little bit because it was getting hard to see, but you can either mark it or do it, but it really works. And studies have shown, Doug Ress has shown even 40 mil and randomized control trials too, that even 40 millimeter polyps, you can get on block. So it buys you about five to eight millimeters extra polyp that a conventional EMR wouldn't have. Yeah. So just a comment about marking. I know we usually use ESC knife. So like we're marking it with the snare. So you need to like use the tip with a special type of setting of the APC machine, like not the APC machine, like the like AirB machine, collaboration machine that you have. And usually do you have it like in a special type of like a setting? Is there any special what that you think works better with the snare or something for marking? Yeah. I mean, I think self-coagulation maybe. Self-coagulation. I agree. Yeah. I will use self-coagulation for it. And it doesn't have to be like extensive, like ESD marking, right? You just want to know left, the lateral position, and then often the proximal portion of the polyp underwater becomes very difficult to find. So just proximal, lateral, and then you're done, you know? So this question about the size of the snare, I think this was 15. So I would like to highlight here in the video. So that's a lesion here with air. And now you're gonna turn off your carbon dioxide and sufflation and keep suctioning the air and put water. See now how the polyps looks different. Now you can see all of it. Now you can see that, okay, I actually didn't get all of it. It's almost when you do underwater MR, is this shaking, you shake your snare. And when you shake your snare, the polyp will go inside the snare and you're gonna get more normal tissue. So a tip and trick for all the fellows who are watching today, when you do underwater, try to shake your snare and get the lesion under it and get the normal tissue and slowly close. And once you close, you really wanna make sure that you get it unblocked. Because as Salman said, you really achieve unblock on most of this lesion, as you can see here. Anecdotally, it's helped a lot with also lesions that are somewhat scarred. You can actually get more tissue this way too. I'm interested in Faris' experience because I always wondered in terms of learning, is conventional EMR easier to learn from fellows or underwater EMR? So I think- From my perspective, I think underwater EMR is a little easier to learn. I feel like the injection part of traditional EMR spreads the polyp, polyp makes it more flat. And you really have to be actually even a better endoscopist to tackle it sequentially, like Dr. Othman will show us next from side to side. Whereas with underwater EMR, you're cleaning, you're flooding, and you're trying to get the lesion unblocked and you're able to maneuver a little easier. So as a fellow, I think underwater is much easier. And I encourage fellows to try to always think of taking these polyps unblocked and try to avoid piecemealing polyps when you don't have to. So if a polyp is under 20 millimeters, think of the ways that you can change your scope position, putting it underwater to try and get a polyp unblocked. And I think underwater is pretty unique. Yeah. So I will show here one of Salman's videos too about underwater. This is the last underwater video we have. And again, Salman, I'm impressed. You know, you're patient in spite of having okay prep, you're able to do underwater. Yeah. People will say you can do even like underwater. Yeah, you just have to flush a lot. In this case, I was trying to show like how I was trying to lift it. It's on the outer lip of the valve. And I see valve polyps are very difficult. And, you know, Mohammed makes it look easy with the ZSDs, but they're still quite challenging, you know, to lift it because they don't lift. The valve is very thick. So you have to find, and there's a high risk of recurrence. And so I was showing kind of like how I was trying to lift it. I just couldn't get this lip, even though the lips in the front, I couldn't even get the back of that really adequate or enough to where I feel like I could grab it and get good chunks. So I eventually just went underwater and I actually got this on block, you know, cause I sent the specimen. I wasn't a hundred percent sure if I got it on block or not, but I sent the specimen separately and they read it as clean margins. So a lot of polyp that I for sure would have been done doing piecemeal or have to do ESD to get it out. I was able to get on block just underwater. This is, I also wanted to show how, you know, like as Firas mentioned, take your time. If you don't feel like, you have to understand how the snare is coming out. That's one of the key techniques. Cause you'll realize this each, every time a snare comes out, it comes out in different directions. So you have to see where it can take. And you have to find an anchoring point and you have to, regardless of what kind of EMR you do, an anchoring point, and then being able to determine the angle of the best opening. And that comes with time, but you can see, like, I think I readjust here cause I see it's coming out to the right of the lesion. And I don't, I don't want that. I think this is when I kind of readjust. Yeah. So I readjust a little bit and then bring it over and you're going to see shortly how it kind of just like pops into it. As Mohamed mentioned, the water. And as you're doing this, you flush the water, sorry, the saline, and it just pops right into the lesion. So here I'm going to do a fine tip control on the right. And then I'm going to, I'm going to flood it with water. And now the pulp is going to pop into that snare. I'm going to push out the snare a little bit just to let it pop out. And then there you go. And it just pops out, you know? So this is, this is actually the whole polyp right here. Yeah. So you got it unblocked, which is actually, initially you would never imagine. Never. I would never. When you inject, this stuff gets larger and gets harder. So I have to make a confession here. I was really, again, it's underwater EMR. And I was saying, this is nonsense for a while. And then I saw some videos and I felt like, you know what? I will give it a trial. So I used Tara as my, usually when I try to experiment with something, ask Tara to do it first, so that if she makes a mistake, she'll be the fellow who made the mistake. And then she did the hospital. It takes you the same time that underwater EMR for many of us to remove the DST. So I kind of can see your point, but I seriously had this experience, especially in the last few weeks and you came to this conclusion with like underwater EMR and I started using it myself as well. It's actually a very convenient tool for certain polyps that is just challenging. You lift it and you think that even if you lift it, it's just like more spread out instead of actually like helping you to put the snare around it. Even like making a tip, anchoring your tip of the snare still doesn't work. And as Dr. Alton mentioned, it's relaxing the muscle layer and actually like holding the mucosa up, it helps. Yeah. And I would mention here, Jason Samarsin, I watched one of his videos and also we were in a pre-victim course. And after that I said, I'm going to do underwater EMR. Honestly, now I use it maybe once or twice weekly. Yeah. For years I was not using it. So I am telling my fellows here, try it. Although the first two or three times it will sound annoying, but once you really get the hang of it and know how to use it, you will really love underwater. But just remember, as Salman was showing the video, clean the area very nice and also like allow your snare to take the entire polyp in. All right. I think when I was trying to start using underwater EMR, it's like literally take your time as Dr. Gervais video mentioned, just like don't rush it. No, like very like a rapid movement. Like, as you said, like the polyp is slowly will come inside the snare and try to have very fine movements. And that will help. It's a little bit different when you have air and air is against you, you're using it, polyp is going away, your scope is pushing back. So use this stability of the water that is giving you actually to your leverage and try to get as much as teacher that you can around the snare. So I have a question, two questions that I noticed. One of them about, if you have two centimeter polyp, do you really use two centimeter snare? I really would say yes. Two centimeter snare is good for two centimeter polyp. Most of the time, especially if you're doing underwater. And even if you raise it vertically, you still can press and you can get more of the polyp. And there was another question here right now about the cap. Yes. Anytime I'm doing pulpectomy, I use a cap. Cap really makes everything better and easier. So since we're talking about pulpectomy techniques, should we just keep going showing other techniques here? So that's the endo loop. And endo loop, and the problem was endo loop is that the technician didn't know how to use it. So it's a great tool. And you can see here what's happening was endo loop is that it has a place, you open and close, and then it has a, when you put your finger in, you don't wanna play with your finger in, you wanna play with that yellow thread and get it down to open it. And you can see it's very flimsy. It's not like a snare. So really you have to lay it down and do the shaking movement. See what I'm doing right now. I'm shaking it, shaking it, and going back with the polyp. And once you shake it enough, you get it. You can see here, I'm leaving the timing for you guys. It didn't take me a long time. It took me exactly 20 seconds to get this endo loop and this very large polyp. But all what I did is that shaking movement. I see people trying the endo loop, they try to use it as a snare, which is to open it that wide and put it as a snare. It's not gonna work this way. As we say in Texas, it ain't gonna work, right? So you have to learn that you have just, you know, to wiggle it a little bit and it will go in. So when you're closing it, your technician should be careful not to cut. And you wanna look at the blanching. And once you have the blanching, now you're gonna put your snare. And see the difference. The snare, I open it all the way to the end, and you're gonna pull it through and easily the snare will be above the endo loop. Endo loop is good for large pedunculated lesion. Alternatively, I know that Salman used something else. He doesn't use endo loop. What do you use, Salman? Well, I mean, what I do with pedunculated polyps is I actually put a clip. Yes, I know. I know. I put a clip. I know there's theoretical arguments against that. I use a clip because I've had a horrible bleed because these things bleed. And the way the stock is, sometimes, most of the time, it's at a place where it's very difficult to find. And so I had to bleed so bad, I had to use a side-viewing scope actually to get to it. And I stopped it with a side-viewing scope in the sigmoid colon. So I basically have now resorted to, I clipped a base as far deep south as possible. And now it can get in the way, so you have to be careful. So I clip it just so I have, A, I have a place, I have more of like a marking in case it bleeds. I know exactly where I'm gonna go after. And B, in my head, I think it may help decrease the rate of bleeding. Some people will put epi and finish the colonoscopy, let the area shrink, and then come back. That's also another trick that people do. But this has worked for me. The downside is if the snare gets, if you grab the polyp and it hits the clip, all that current density is directed towards that clip. So theoretically, you can get a perforation. So you have to be very careful with that technique. But the point of it is the bleeding that occurred, although I'm very comfortable with treating bleeding, the bleeding that occurs from pedunculated polyps when it occurs can be quite bad, if you will, lack of better terms. So that's what I do. I wanna ask the panel, and a very good question about this, is there's this theoretical risk of deep invasion in the stock. And I think I read an editorial by Dr. Doug Rex, and he argues against using end-loop or clipping, because just by definition, no matter how low you go, you are forced to cut above your tool. And in a certain percentage of these polyps, you're missing, your pathology is gonna come back with positive margins. It's gonna be rare, but when it happens, you've taken the chance away from the curve. What do you guys think about that? Would you rather worry about that or worry about the bleeding? No, no, no. So I agree. First of all, if the stock isn't very long, I try not to clip, because I'm trying to get as far down as possible. But if the stock is very long, and you can get like three-fourths down with the snare on the stock, you're gonna be able to get any submucosal invasion. There are very few. And you'll be able to tell from the top of the polyp, like that polyp right there, that's not gonna have deep submucosal invasion. So you can get like half of the stock. So in my view, you should be getting at least three-fourths of the stock, if not lower than that. So question about how low you can go if you open the polyp. Yes, when you open it, the polyp will open all the way to the end. Automatically, so you will have to leave it to the end. In terms of how low you go, you wanna go as low as you can at the base of the undulated polyps. So in summary, if the undulated polyp first is too long, your chance of having invasion is too deep if all this normal tissue is good. But you have sometimes stock that's very short. That's when I actually ESD it. Yeah. And I ESD under the base of the submucosa. So that's happened. So I would like here to show a video of the piecemeal EMR, the standard old-fashioned piecemeal EMR when you raise, inject, and dissect. By the way, you can do all of this now, piecemeal EMR underwater, honestly, and it works very well too. And also you can do cold snare piecemeal EMR. So that's how we evolved in the last five years in pelvectomies. You have the option of cold snare, you have the option of underwater, and also you have the option of snare anchoring tape or pre-cut EMR. You have a lot of beautiful options that we can use now. So I'm using a leptin agent here, by the way. That's not a regular normal saline. And you can see that when you are using a leptin agent, it really raises the lesion in a uniform way. And you notice here, this was a bad injection. I don't know if you guys noticed that. Clara, what's wrong with this injection here at the end? I'm going to show it to you. Well, I mean, this is something that usually, like I learned it from you, Lester, that the concept of ionizing injection. You first start with the part that is less visible to you to start injecting to make it more visible to you. Then you have to go next to it and around it in a circular fashion to make it in a way. And avoid making, because after your term, avoid making any valleys. Means that your mucosa goes down. You want to have everything uniform in a flat surface that when you put your snare around it or you go for a dissection with ESC, you really have a good area. Like I can see a little bit of maybe valley on the other side and the way that you injected, like you injected maybe more proximal, so you couldn't see the lateral side. I think at the end, it was saved perfectly well. But the timing, at some moment when you're injecting, you actually can go against yourself and make your life harder. So I have to do a disclaimer here. I use certified 20-meter snare and I'll tell you just saying how much I use it. But I'll tell you why I use it. Look at how much raised area we have. I felt very safe and was using this agent. And if you're able to have this good lifting, you really can get most of the polyp like that in one area without getting the fold. So what you worry about when you do this is to get the fold. And exactly as Tara said, dynamic injection. If I didn't really raise all these now to be even, then I wouldn't be able to remove all of this now in one piece. And in spite of that, we're gonna find that we still have residual pieces that we'll have to take care of. So go back here. Now we still have that margin and always try to take normal tissue next to the abnormal one. Use whatever you dissected as your anchor. And you can see here. And then you can see you can switch now to smaller snares. If your snare is too large, as Tara said before, if you have a five millimeter area and you use 35 millimeter snare, it's not gonna be helpful. This shaking movement I did is totally useless. I stopped doing it. I just turned it. No need to do it, honestly. I think it makes us feel good. Yes, but you know, it's like the things you keep learning. One generation, send it to the other, to the other. Yeah. Any evidence. Yeah, I stopped. Yeah. Yeah, actually, yeah. I think I don't shake anymore because they allow the machine to just cut by itself. Yeah. I don't know if you mentioned this. Just kind of continue on with EMR. I mean, that's really what you're talking about, but you don't need to inject everything all at once. You may have mentioned this. I don't remember. Inject the area you can't see, as Tara and Mohamed mentioned. Take care of that. And then, because you can always keep injecting, but you can't take the injector away, especially if you're using other agents. So we were, I was showing here the part about using the hot snare for the residual area. And I hope that this would work there. So we can see here, once you get here, you can see here that I'm using hot biopsy forceps and hot biopsy forceps came back. You know, you use it now either with soft coagulation or endocut I, and you can pull the tissue away. I would recommend, at that time, I was using it with soft coagulation. Now I use it with incision. Endocut I, and you pull away. The idea that you pull away from the tissue and you make sure that if there's any residual, you remove it. So that's another tool now you have. If you have residual tissue, you can use hot biopsy forceps, but not with forced coagulation. You can use it with soft coagulation. That's another. So I want to show this video. This was from one of my early experience. And actually, I'm not proud of this video. And I wanted to show a video that I didn't do a good job. And I want to see why it's not a good job. So you can see here, this is granular lateral spreading, right? It's small granule. And you can see it is over a fold. And, you know, I removed the year. This was maybe 2015 or something. So I raised all of it uniformly here. I'm fine here, but you notice in the middle, I might lift a value. This is what Tara was talking about. I'm doing a slobby job with injection. You can see here, it's not like very careful. I'm going tangential. I'm not really looking where all the polyps, but it is raising. And then now we're putting the snare all the way further. Can you notice here, I have a dip. It's not raised. So Tara was talking about. You have to have uniform elevation. See what would happen now. You have a area raised here, area raised there, dip in the middle. You get a large piece. You are so excited. I did a good job. Yes, I removed it here. Oops, I didn't remove the little part. Uh-oh, I removed the part here. That's a slobby job. You don't want to do that. Don't be like me in this video. And this happened because I did not inject enough. I actually inject all the way around it and lift the middle part. So now to salvage this, you will have to use the area that you like your snare and use it for your favor to use it to anchor and remove that piece. You can see here that we have a significant looping. Now we have a stabilization devices. If I use it in that case, it would make it goes much better. But in spite of me doing this, I'm not able to remove it in one piece. So now that procedure, instead of being cool and elegant and can take like two pieces and you remove it, now it became harder, because simply I did not inject enough in the middle. And now injection was not helping me because I raised so much out there that the lesion become depressed. So don't get so excited about injecting too much in the normal tissue and leaving the polyp. And then you end up in a situation that you have to salvage it. Finally, after removing two pieces, I was able to get my snare in a good position. And finally I was able to do it with no problem here. But the lesson is you have to have uniform injection. I would do what Salman would do in this lesion, inject a little bit area first and remove it, then inject another area and remove it. And instead of injecting everything and end up in this situation here. So quickly, because people don't do this a lot anymore, but CAP assists the DMR, please do not do it in the colon. I don't know who, sometimes people think they can put a cap anywhere. The wall of the colon is so thin, you're going to take the muscle and you're going to have perforation and do not do it in the duodenum. I saw people do it in the duodenum though. It is designed to be done in the esophagus. And my first perforation as an advanced fellow was in a neuroendocrine tumor in the stomach that we removed it was CAP. And we learned at that time that maybe it's not a good idea to use CAP assisted EMR for neuroendocrine tumor in the cardiac areas like that. So all of these are methods to help you use EMR. And now I'm going to go back to the hemostasis agents. And we're almost there. I think now we're on time, we're going well. So hemostasis devices are Eclipse and Agent. We have a lot of agents now, Salman and Tara, you have tried some of them. I'm going to start first with this one here because I know that Salman tried it. And you tell me your experience with this one. Puristat is self-assembling peptides. Yeah, no, it works. Meaning in a sense that unlike hemo spray, everything is visible and nothing gets kind of clouded. I didn't feel like it works, but I think it's not, I think it slows things down, but doesn't entirely like stop it. So it allows you to kind of slow down the area and then treat it definitively with maybe a coagulation grasper. But the other benefit of Puristat, it also can be a covering agent. So if there's any, you may not have to close the resection bed, if you will, to decrease the delayed bleeding risks. I'm going to talk about complication like perforation later on. But yeah, this agent can help with bleeding, allow you to dissect when you're working. And then another, there's a study about it in controlled bleeding. It's really the evidence show it doesn't really control bleeding in every cases. As you can see here, it's around like 60 to 70% at maximum 80%. There's another agent that's called Endoclot, which have a study for it here. And that's one, you can put it post ESD and it's one study showing how it really helps with hemostasis and prevent bleeding. And honestly, Ferris and I did this. We used one agent after EMR and we sprayed it very well. And then he bled a still. So I don't think like this stuff is full bloom 100%. Tara, you want to talk about that agent? Yeah, actually the next powder. We use it, this is one of the newer agents that use it post ESC in the ESC bed. And just wait, this powder after a few seconds, it turns to like this gelatin like a coat, but it's hard and it's going to protect the surface. And just give it a few seconds and you can see it turns into this blue greenish solution I'm not sure if in this video you have the moment I'm tapping also, but the tip, as you can see, it becomes this hard, thick covering solution, like a cover. We had few experiences and this patient actually did very well with this large lesion and we didn't close it. Yeah, so Ferris was in the room and he said, you guys have to close this, it has muscle injury. Then I told him, no, Ferris, we're not going to close it. And yes, patient did well. So I don't think we have enough time to talk about closure devices, but there's many of them at the market. And we had very cool videos about how you close post EMR and how you suture, but I don't think we have time. Also stabilization devices for post EMR and ESDs are good. Little bit about adverse event bleeding, we covered it right now. I want to talk a little bit about post resection syndrome. As an advanced fellow, Ferris, what's your experience with it? Since you see a lot of our resection cases. Yeah, I feel like because we apply controlled current, we're not seeing a lot of post resection syndrome. And we also, I think a lot of our practice is ESD where current is a lot more focused and the area is a little protected, though we do see it more in duodenal lesions. That's the few that I have seen. It can be scary when patients come back, they're in pain, they have a white count. You're debating, do I get a CT scan? Are they going to have free air? It can be scary and a lot of the time it does resolve with conservative management. Yeah, so a lot of time post resection syndrome, they want to send patient for surgery just because they have pain and fever abdominal. And then if you know you have a good closure and that's why we have enough data now that clipping can go and prevent bleeding, but I also believe that it decreases the risk of post resection syndrome. That's a nice classification that Tara wanted to share with the fellows. She said, please, I want to talk about that. So we'll give you the stage, Tara, to talk about it. Yeah, this is actually very important to know because I mean, I, each year even, I was like, look at the target sign, let's just see the target sign. Me, generally speaking, don't want to see the target sign, but you want to have an idea, like how much of the defect you see in the mucosa and what is that actually? The Sydney classification helps you from type one, actually type of four to see like the degree of invasion from the sub-mucosa to the musculoskeletal, which is like type four, which is completely true. And then type zero, which is like very early stages to the upper higher level of the sub-mucosa. And you have to know that when you definitely need to go for closure and definitely type two, type three, type four, you have to have a very full closure. Type one, type zero is something that you can actually like maybe need no closure. If you have no bleeding, it's okay. And the size of the lesion is not big enough. And type one definitely depends on the size of the lesion. And if you had any other like complication or like something like bleeding or something else happened during procedure. Yeah, so type five is fecal contamination. You know, you make a hole like type four and then after you make the hole, you know, the stool goes out from it to the peritoneum. That's bad, you know. That happened, I would say, go out of the hole and wash everything and clean the stool. It's true. But I would think I would do that, honestly, if that happened. And that tells you, well, when you get in park in these cases, you have to have a good prep in most of the situation to prevent type five or soil contaminant from happening. We will finalize now with a video for closure. This is an EMR. I don't know if you guys saw the perforation here, that it was there. It was nice and nobody noticed it. And now you can see. Can you see it now? It peaks down there here, right? With the fat looking at you. Luckily we're using Overtube and to the rescue is a suturing device. By the way, you don't have any good insufflation in this situation. So you can insufflate as much as you can. You're not gonna see much. Try to as much as you can to place one suture here and there, and then insufflate because you're gonna start to distend the colon and everything looks good, as you can see here. So with that, I think we are almost time. I'll tell you, thank you so much for this. This was great discussion, guys. Thank you for the panel. This was amazing. We answered all the fellow questions and it was an engaging discussion. I encourage the fellows, we have about maybe a minute if anybody has any burning remaining questions, otherwise we'll probably call it a night. Okay, I think Marilyn now, she will give her the... Yes, thank you all again to all our moderators and panelists for tonight's session. Before we close out, I just wanna let the audience know to make sure to check out some upcoming ASG educational events. Pay particular attention to the save the date for September 22nd, 23rd advanced fellows course taking place at the ASG IT&T center. Hands-on will be part of that course as well. Save the date for the next ENDO Hangout session, Thursday, April 6th, 7 to 8.30 PM central time, incorporating new skills into your practice fellowship and beyond. Cylindra Stein from the West Virginia University of School will be hosting. And 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 ASG and we wanna make sure our offering are interactive or that fit your educational needs. As a final reminder, ASG membership for fellows is $25 per year. If you haven't joined, please contact our membership. In closing, thank you again to all 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. Thank you.

Hespan solution

methylene blue

saline

polypectomy procedures

scar tissue

granulation

injection solutions

snare sizes

underwater EMR

stabilization devices

hemostasis agents

post-resection syndrome