All right, we've got a 68-year-old male referred to us here at IU in August for a section of a 70-millimeter granular homogenous lesion in the rectum removed by EMR. Pathology was tubulovilous adenoma with high-grade dysplasia. During that colonoscopy, there was noted a 30-millimeter lesion, Paris IIa classification in the cecum and other small polyps. None were biopsied or removed. So in this case, we'll talk about reviewing synchronous disease in patients with large non-penunculated adenomas and assess the rectal scar for recurrence and resect cecal lesion by EMR and demonstrate mantle-slip closure. We'll talk about injection fluids and dynamic injection and clear the colon. So here we are at the lesion here. Again, it's about a 30-millimeter lesion, non-granular, flat-elevated. I've kind of been looking at it. So you can see it kind of stretches out here, the boundaries of it, stretches up here, stretches up here. And then down here, there's another lesion, slightly smaller, obviously. Don, apparently this lesion was missed in the previous endoscopy. Do you have any reasoning why this lesion was missed? Is it because maybe they didn't get in the cecum or they get in the cecum and they didn't find it because it was very flat? Can TSI help you? Yeah, I think it's very flat. His prep, I've actually been cleaning up while we were waiting. So I'm not sure if it was because of his prep initially. And sometimes we find that people just find these gigantic polyps, maybe in the rectum, and they just kind of almost shut their brain off. I mean, about, I think, 20% of the time when we get a referral, there's another large polyp that we might find. And there's been a few cases where we found cancer in another lesion. It's a good point, John. I think it's a point, when you're referred for the resection, how you discuss that with the patient, that you haven't cleared their colon and the importance of that in a follow-up exam or not. The other thing I want to point out about this... Go ahead, Cesare. In my view, the expert endoscopy in a resection has also a higher detection for flat lesion. So I'm not surprised that an expert endoscopist detect more flat lesion than endoscopists who are not experts in removing lesion, in doing advanced endoscopy. And this tells you that the miss rate of polyp is overall 30%, but probably the miss rate of advanced flat neoplasia is much higher than 30%. And this is very much more worrisome than... Yeah. Okay. So... So the thing about this lesion is that it's possible it could have been missed because if you look at the pit pattern, I think a lot of endoscopists now are identifying the 3L pit pattern. This looks like it's 3S. And what I tell the fellows is something unusual. With TXI, we didn't talk about this too much. You can really look at the pit pattern very well. It's a little, for me, troubling sometimes because the normal pit pattern with a little bit of submucosal abnormality, very subtle lymphoid stuff can sometimes look like a polyp. And so I'm having trouble discerning that. But this has a 3S pit pattern, it looks like. And I think you could miss that. And what I tell the fellows is that when you see something that looks abnormal, pull away because what you may be looking at is a very large polyp. Now, I don't know if that was the case here. John, are you going to attempt to do this cold or... No, I'm going to take this out hot. I think you could take it out cold, but it does have a slightly higher risk of cancer because it is non-granular. Yeah. I mean, talk about that, John, more. I mean, talk about the pattern of this because this lesion has... I don't think you showed certain areas, but I mean, the approach to this endoscopically so much as what you think the histology is, right? So can you talk about how you're interpreting this? I didn't see any kind of disruption in the vascular pattern, which would make me concerned that it's overtly cancerous. But in a lesion like this, this size, non-granular, flat elevated, there is probably a 5% to 10% chance of this having cancer. I don't think this has cancer. But that's going to kind of inform my approach. Our approach for taking out cold EMR lesions is really, for big things, it's mostly would be a granular lesion, regardless of size, really. And probably without a nodule. I mean, a homogeneous granular lesion, no nodular. So really, like an extremely low risk of cancer. You know, a granular lesion would be one... If it was here in the CK, it would probably be about 1% risk of cancer. So Doug and John, I mean, there are a bunch of questions on all of these cases in which piecemeal resections are being done. When do you typically bring these patients back? It depends on the path. So close for me. So any lesion with high grade dysplasia, we're we usually have them come back in six months after a piecemeal resection. Sometimes with if there's, if it's a low risk lesion is a no high grade dysplasia, we have been pushing these patients out to a year. A lot of our cold EMR patients that we're doing cold EMR on, we push them out to a year. And a lot of times that's to give the chance for things to grow close. But that's not in the guidelines. That's something that we've recently published. But the guidelines would say, if you have a 20 millimeter or larger lesion that you've removed piecemeal, the standard thing would still be a six month follow-up. And so we're, we're sort of investigating this whole thing of, of doing this. Gotcha. Okay. Just for the audience, please put your questions in the Q and A box rather than in the chat box so that we can get to them. And several of you are asking if this recording will be available and that's it. Yes. On GI leap. So those are some standard questions which are coming up. Go ahead, Tanya. Oh, I was just going to ask John and Doug, talk about the approach here. Cause these lesions are hard to capture. One of the questions is like, when would you ESD or FTRD this before even getting into that? You have this nice access to the submucosa, John, right? So talk about once you get that access, how are you maintaining the plane and keeping there? I think that would be important for the audience. I'm already kind of struggling to get tissue in the snare. So I was actually thinking about kind of sucking some of this up and what we call the cap technique. And so close. And my tech is going to tell me when he has a good chunk of tissue and you can see we have a good chunk there. So we're going to come through here. We use this cap technique when we have tissue that's really flat or fibrotic. But going back to your question, Tanya, which I think is a really good one for FTRD, I think this would be possibly too big to get it in. I mean, you could pull on it. You might miss some of the edges at 15 millimeters. You know, you have basically almost 100 percent success rate with FTRD at 20 millimeters. It starts dropping. It's nice and flat. And that would be an advantage for FTRD. So the other thing is to use Chesseries technique he's been talking about underwater and non-granular lesions that are, you know, they're very flat like this one. And then you inject them and they get even flatter. And so that's part of the issue here. I mean, we had sort of planned, I think, to do this like this. But I will say that if we had stayed underwater and let everything relax, you know, we might have had the snaring here would have been a lot easier. And I think in the next case where we're tentatively planning on demonstrating that. But right now, I think what John's demonstrating with this CAP technique is it can be very useful. And this is this device we have on the end of the scope here is the Olympus distal attachment. It's not a like a, you know, the Wilson Cook duet device that we would use to perform EMR in the esophagus. It is simply a short, soft plastic cap that is sticking out of the end of the scope by about three or four millimeters. And that's what creates the safety, allowing you to suck some tissue up. Because if you don't suck it here, we're having a hard time snaring it. And so I think that this approach that John's using is one tool you can use for really flat or fibrotic tissue. So he's got over the tissue. Now he's going to suck it. But point out where that snare is. It's right in that submucosal next to the mucosa, which also gives you the plane so you don't perforate. I mean, I think that's an important, important point in the technique. Yeah, yeah. And John is John our tech. We're using a 15 millimeter right now. Usually when we're doing this, we will restrain the snare size to around 10 or 15 millimeters, because it's partly a blind technique. If you watch John executing it here, you'll see that he lays the snare out on the tissue. And then when you suck the tissue up through the snare into this little cap, at that point, we can't see anymore. And so our tech John is going entirely by feel. And that requires some some skill and a bit of experience. And he's a he's a master of it. But when you first start start off, we actually sometimes will use a an 11 millimeter snare, a captive flex, a Boston captive flex, because it has a very smooth, open and closed technique, the throw on it is very smooth. And it's easier for the tech to get the handle of feeling it. But John and Ryan can do this with a stiff snare. This is a 15 millimeter captivator, a stiffer snare. Generally, we want stiffer snares for EMR. And but not too big a snare for this technique, because you don't want to be a huge snare out there, closing on stuff when you can't see. And again, if you watch John do this, put the snare out, and then approach the tissue very closely. Because if you stay too far away from it, you will get So Doug, there's some question about the type of snare, would you when you aren't able to raise or suction it well, do you ever try switching snares? Like there's a question, would you end up using a duckbill snare ever? Would you try that? What's the philosophy behind? Yeah, I hear no, I hear you Prateek. And you guys should discuss that. We tend to stick with with this set of of snares. But there are monofilament snares, you know, that are that are very thin wired that can help you get flat tissue. The duckbill is preferred by some, some prefer a hexagonal shape. And, you know, so I think that it's a little bit of a matter of personal preference. We tend to go straight to this cap technique to, to get the, the really flat or fibrotic stuff off. And I think John demonstrated that, right, you know, very, very nice. Hex snare, I don't know if anybody on the panel uses a hex snare or not. But we've had good luck using that. But this small reference, okay. I was just gonna say while he's doing this, that the size of this is really important, like Doug saying, like, if it's too big, you're not going to be able to grab that nicely, because it'll, it'll, it'll slip. So I don't know, I think that that looked great. Yeah, I he's getting a nice amount, you notice that when he sucks it up, and then john closes it, and then john is actually telling him, you can't hear that. But john says to, to, to john Guardiola, I've got it now. And then john is releasing the suction. So we can sort of eyeball what we have before, before we actually transect the tissue. This is a really nice demonstration, john, if you can stop for a second, you see these two areas of polyp. And in between them, you see a thin white sheet, right, the muscularis mucosa. And that's a really critical thing to be able to recognize during EMR off. If you look at the outside of the snare, right now, you see those thin white lacy fibers, that's submucosa. But in the middle of the snare, we see some obvious residual polyp. And we see that thin white sheet of muscularis mucosa. And I think that's an important area to completely resect to have, you know, to lower your occurrence rate. So now this, you know, right there, you know, we missed with the snaring. And that, you know, that that happens sometimes. And we would, we generally will use the CAP technique first. But if we sort of get stuck, then we would go to avulsion. The thing about avulsion is it's just not as fast. Now, a lot of people in the past would stop at this point, and ablate this with the argon plasma coagulator. And that's something that right now we think is probably not the right thing to do. Because that's associated with a higher risk rate, a higher risk of recurrence. So John tried a couple times with the CAP. And he's just asked our tech to get the avulsion forceps. And we're going to switch over to endocut I. So we're using cutting current endocut. And we have this on the 141 setting. So we have it almost on pure cutting current. So while I don't like that, yeah, go ahead, Sashre. After the previous and this EMR, it was coming to my mind. Is there any danger in clipping an ulcer when recurrence could come. Is a clipping causing possibly buried adenoma recurrence to come back and we miss that surveillance for this? Sure, great question. I don't think there's any evidence for that. I will tell you that we tend to, I don't think we've ever seen recurrence around a clip. We have, let me back away from that a little bit more. We do occasionally on a referral see a partially resected polyp and somebody will close the site right next to residual polyp and then we have to cut the clip out. But for our own clip closures, I don't remember ever seeing actually that there was a clip with polyp around the base of it. Nor do I know that buried polyp is like a real phenomenon. Doug, so John's doing good in which he's stenting it away from it using that hot evulsion. We've moved to like cold evulsion in this in which we just use a large capacity biopsy forceps and just evolves it with cold. I mean, any thoughts around that? Why do you prefer the hot over the cold? I partly, I have to admit that it's a little bit of been our habit. One thing I like about it is that I think it's very clean. I think most of the people who advocate cold evulsion are worried about the risk of it. Right now we don't have any evidence that the risk is higher. John's doing it very carefully. Notice how he just gets the forceps overlying the polyp. They're not picking up a ton of adjacent submucosa. And then he's tapping the yellow petal. And with each tap, you can sort of see the tissue tear away from the submucosa. When you do it cold, my experience is you see a lot of blood, then you got to get another tool out. You got to take the snare tip to do it right if you're doing the cast technique. And so I just think it's a matter of, we sort of think- But it's just another technique that's available to remove residual tissue. The cold forceps removal is another tool. If that's what you're saying, Prateek, I agree with you there. Yeah. So again, just like that we have some options here as well. We haven't heard from Joe in a while. Joe, any, you know, I know you've been very patient because Cesare keeps talking over you, but we'll give you the floor now. So put Cesare on mute for five minutes. So Joe, go ahead. I've been very humbled by the people that I'm around. Like a lot of the things that I've learned is from Heiko as well, like Heiko Paul. But, you know, one of the couple of things that you guys reviewed that I had questions about was certainly the hot avulsion, the cold avulsion. I think that sometimes when you try cold avulsion on the first time that you're resecting, you may not be able to pull away. You may need heat. And can you just, John, just go over, when you're doing hot avulsion, as Doug pointed out, you're taking a tip, right? And you don't want to pull away so quickly that it becomes cold. It's sort of like a feel, right? Where you're applying the heat just as you're pulling away. So it's sort of like you have to do it in one fell swoop, so to speak. Yeah, that was the thing I struggled with the most was wanting to kind of pull it away at the same time. And that kind of defeats the whole purpose because you end up having bleeding. And so you're basically doing it cold. So there's really no point. Maybe a little bit more out. And then the other question, John, is now you're going to go and treat it with the Snare Tip Soft Coag. But when you're inspecting, now you did a great job of really overlapping the polyp, really doing a good job of getting a wide resection. And there is a side of, there's another polyp to the side that everybody sees that probably is a separate polyp. But when you inspect, do you look at the pit pattern? Like, what do you do to say that, hey, I have a clean- So there was an area up here that we were concerned might have polyp tissue, but to me, it looks like normal tissue. And you use that pit pattern, right? I mean, sometimes- Yeah, I use the pit pattern. So, you know, these are all just normal pits. And then- Circular pits, that's what the registrar should be looking for. You see those little small pits, they're kind of white right along the edge. And yeah, that's, you're exactly right, Joe. That's what we're looking for here. And we had thought about, this might be normal tissue, but you know what, I think it might have some adenoma tissue. And so I'm gonna, kind of looks like it's in the middle of the base there. So I'm gonna take that off with hot avulsion right now. But I think, Joe, your point is really good because some people think, you know, part of the reason snare tip soft coag works well is that it forces you to go around the entire margin. And at some point you might see that there's actually some visible residual polyp that you still need to resect with snare or avulsion or something. And so, you know, I think your point about, you wanna inspect because our goal is in EMR, we're gonna resect everything that could possibly be polyp. Now the snare tip soft coag phenomenon that John's doing route now is basically, we believe the polyp is fully resected, but what snare tip soft coag has taught us is that there must be some residual cells on the margin that are surviving that we can't see. And if we burn, if we thermally ablate the margin, even though it appears normal, we reduce the recurrence rate by, you know, 75% across the literature. And John, so for these types of polyps after you're done resecting, which are the ones that you decide to prophylactically close? So we close anything based on the CLIP trial that's greater than 20, removed with electrocautery and proximal to the splenic flexure. And anything else we don't really close unless for specific reasons, but. How about patients on anticoagulations or DOACs and stuff? Does that change your practice, John? I think we usually just hold the DOACs. Some very high risk patients who need to be on their blood thinners, we might consider closing defects outside of those indications, or if they have a lot of advanced kidney disease or cirrhosis. Most of the time we're holding the DOACs, you know, for a couple of days beforehand and restarting them the next day. Occasionally we will ask if we have permission from cardiology, whoever's prescribing it, you know, can we stay off a few days longer? But yeah, so, but your point, I think Prateek, is that we don't have enough data on intermediate lesions. We know that DOACs, antiplatelet agents like clopidogrel, you know, are a risk factor. I think we're gonna switch, John's gonna switch snares here because we're not getting a great thermal injury. It's always harder to do this when you're on FOS. We're just directly looking into the cecum here. And, you know, it's easier to do snare tip. Well, like the case that I had the last time, I was very, had a very tangential approach. And John's trying to work his way around a little bit now to get a little bit more tangential here, just so it's easier. We got a couple of little small lesions that we'll wanna take off cold probably before we close this. But I think- Greg. Yeah, go ahead, Cesare. In your own experience, did you notice a dramatic decrease of recurrence since you started in your own clinic deep snare coagulation? Yeah, we have had a reduction that's been pretty substantial. Cesare, you may know that we did a randomized trial comparing snare tip to argon plasma coagulation for the same purpose. And our, it was a multi-center study, but our recurrence rate with the technique with the snare tip was right at 5%. And our traditional recurrence rate has been 13 to 15%. Like for everybody, you know, it's size related. So the bigger the lesion is, the greater the recurrence rate. And so, but so yes, we've had improvement with it. But Cesare, are you sort of a doubter about snare tip soft coag? Where, what are you getting at? Yeah, I mean, I still have some personal doubt. For instance, why didn't wide field EMR succeed where deep snaring is succeeding? And secondly, if you control with TXI or with NBI, the margin, and there is really nothing and you did a very good EMR, are you confident you need to do in all the cases? Does the exploration of the margin be useless if you need to do all the time? Sure, I think your points are, there's some things we just don't understand. You know, we have to remember that the original comparison by Michael Burke of wide field actually utilized historical controls. And so that could be a problem. I don't think that there's a randomized controlled trial comparing wide field to snare tip. And, you know, maybe that would be a good trial. I see your point that it's hard for us to understand, you know, some of these issues. But, you know, I think right now we sort of have to go where the data is. And the data is that thermal ablation of the margin reduces the risk substantially. John's got the Mantis closure clip out here. John, you wanna talk about this? So we published a paper recently about it. This is the Boston clip that has little jaws on the end of it. Their intended use for it is to grasp the tissue on one side and then bring it over, open the clip up and then grasp again and close it that way. Well, we call that the grasp and drag. What we end up using usually is what we call the open jaw technique. So I'm just gonna, you know, it's a little bit harder because it is on FOSS, but I wanna show this technique. So we try to hook it on there and then this lesion is actually not that big. And yeah, cause I don't think I even need to really use this for that, but you can try to close it there and then fire. And what we really look for when they're using that technique is kind of this, it's like a bow tie or a butterfly or farfalle, I guess if we're talking about pasta, kind of shape. And then the rest of the time we can just use normal clips to close it on either side of it. Clips on the market. Zona, Zona, what does to close an ulcer mean? It means that you don't want to see any submucosa and that you put the two margins fully overlapping. How do you define close an ulcer? I define close. I don't wanna see any submucosa. To me, that's the successful closure. And so I start there to kind of bring it together and then I'm gonna push more clips here and kind of zipper it on either side, close and fire. And so we will completely close this because with incomplete closures, you do have a higher risk of bleeding. So I wanna see no submucosa visible. And that's where the lifting with the dye helps too. It's blue, so kind of have a good idea of what to see. I think we have to wrap it up, but I'm not sure. John, and John, the other thing is that the cecum is the highest risk for bleeding, right? And so you really wanna be careful here, especially. Great thin wall too. Right, and so the distance between the clips, I mean, it's always nice to have right next to each other, but what's the minimum distance that you may wanna sort of see? This is beautiful. This is like, you know, like right next to each other. I mean, I think this is bringing up the problem of why we say, why there are some studies showing and doubting the prophylactic clip closures because how the problem with endoscopy research is how close are they putting their clips together? Yeah, there's so many variables. There's so much technique involved in endoscopy more than just the device, right? So I think that's why it's difficult to interpret the operator inter performance. But in this case too, I think John, in that first one, even if you get submucosa to submucosa closure, it brings it closer together. And then you can go with these smaller clips, like you're saying, and get that nice mucosa to mucosa deep. You're trying to get down to the muscle, right? To get a tight closure, you're suctioning. When you do that to grab more tissue, I think, again, there are certain things within clipping that you can optimize your closure, even with a small clip. That's a good point is that, you know, before things like Mantis or Extact, these other closure devices, we would often just put clips in the middle of the submucosal defect to try to get it to kind of bunch up. And I know he'd been doing that for years and never had any issues with it. So I think- You can see even nicely there that submucosa there, see everyone that he has. And now it pinched it together and then you can try to get then the mucosa on the others. Just think it shows that nicely. Yeah, this is very nice. But when I look at it, I don't know if this is the same in the US as in Europe, but it is clear that the most expensive part of EMR is now the suturing. I mean, the closing is somewhat a substantial cost of all the procedure. Of course, there is clinical benefit, but this opened the way to possible competitors because here we are talking about quite a costly part of the procedure. Maybe there may be a faster and more effective way of suturing an EMR device. Right. Okay, Cesare, we need to move to next room. So can we go to room three now? And I think Doug's ready for us. Thanks, John. Thanks everyone.

endoscopic mucosal resection

tubulovilous adenoma

high-grade dysplasia

synchronous disease

flat lesions

advanced endoscopy skills

lesion closure techniques