All right, we've got a 70-year-old male who came to an outside institution in July this year with rectal bleeding. The colonoscopy, there were four polyps, two to six millimeters in size. They were removed by cold snare, and they were tubular adenomas. There's a colo-colonic anastomosis in the descending colon. There's bleeding from radiation proctopathy, and there's a 30-year-old male who had a Yeah, we're kind of continuing this closure discussion here, and my intent was actually to have this lesion out, needle back, but my fellow, Neil and Ben, who was putting it in, putting the scope in, found a couple of other decent-sized polyps, kind of reinforcing that issue that a lot of these people have quite a burden of other disease, and so this lesion is actually in the left colon, and I have our nurse, Brittany, here helping because, and she's giving what we call cracoid pressure inject, because this guy is passing just all of the gas that we're putting into his colon, and so Britt is helping out, needle back, and let's get maybe about a 20-millimeter snare. So it looks like an homogeneous granular LST, or did you see any nodule? I don't think that nodule right there in the middle of it is really an important nodule. It has a little bit of a funky appearance to it. I would not be totally surprised if it's a TSA, but I usually am surprised when there's a TSA, but occasionally I guess right, but I agree in terms of the morphology open that it's a, it is a homogeneous granular lesion. Okay, Rye. I agree though, Doug, that those, the fronds, those villi, the location, and certainly Joe can comment more as the serrated expert here, but I think it has that appearance of a TSA. I found in these larger lesions on the left colon that have that appearance, we get that histology often as well. Yeah, I always say it's a little bit hard to articulate. Maybe you can do it better than I, are you open all the way, Rye? Maybe you can do it better than I can, Tanya, about when you sort of think it's a TSA, but it has to do with that particular. Right there, like you can see the fronds and like that, the villi, they're not villi secreting the mucus like they do in a tubular villus adenoma, but it's more so. This is a TSA, this is a TSA, for sure. Yeah. 100%. Yeah. That's great. Wow. I love that. One of the things you have to remember too is the fact that one of my good friends, Amitav Shirastavi, wrote this editorial, sort of saying that if we're recognizing them on the left side, because you're right, Tanya, that they're on the left side, but there are probably a lot of right-sided villus lesions that were called villus that may actually be TSAs. If you stain them for P53 and other stains, you see that they're probably more likely to be TSA. I'd be very surprised if this did not come out to be a TSA. That's great. I appreciate the confidence, because I had the thought open, but sometimes when I think it's going to be, I'm wrong. As we all know, TSAs, I mean, Joe, can you talk about them? I think that's part of my problem right there. TSAs, can you talk about them a little bit, because they're kind of rare lesions. They're rare, but probably not as rare as we think. They're kind of different than the typical serrated lesions, the SSP or the HP, because of the fact that while they do have methylation, they have cytological dysplasia. Their serrations, unlike the serrations that you see in a microvesicular HP or certainly in SSP, their serrations are real. Those are the ones that can really cut. That's why they have that more, as you described, frond-like appearance that are very similar to villus. But these lesions, when you talk to pathologists, they fear these lesions more than even SSPs with dysplasia because of the mutation. Doug, you are doing a really marvelous EMR. Can you explain your strategy? It seems to me that you always want to take some healthy margin. You went around all the lesions. Can you tell us your strategy in EMR? Yeah. Give me a small snare for a second, please. Yes, I agree that in general, if we're injected pretty well, that we want to have a margin of visible tissue. And I don't truthfully know what that should be, but probably something, a few millimeters generally. I don't go hog wild with taking huge amounts of normal tissue, but I will take off a chunk of normal tissue if I think it's well injected, if it's in the way open. Now, we're switching a little bit smaller snare here just to finish off. And part of that, I think, Chesiree is specifically... Okay, Ryan. So I don't cut off a bunch more normal tissue than I normally need. Anyway, you go from the periphery to the center. This was my feeling, that you were going from the periphery and then only at the end to the center if needed. I'm not sure I'm following you there, Chesiree. I think you start at the periphery to get your semicostal access and then you move to the center. I think that's what you're saying. Oh, I see. Yes. Yeah. That makes sense. Let's put the snare tip out real quick. Oh, I do. Yeah. The traditional serrated too, I think you demonstrate this. They lift well, they cut easily, they don't have that fibrosis, all those things I feel like are characteristics when you're resecting them that might prompt you into the higher confidence of predicting that too, Doug. Maybe you can comment. Okay. I appreciate that, Tanya. Thank you. Thank you for that comment. I think I'm learning from you there because I think we don't have ... When we start talking about TSAs, everybody's kind of got their personal experience, so I like that tip. Comment maybe ... Your assistant, Bryn, Brittany, I'm forgetting, but comment on the importance to the audience with your assistant, like the snare closure, the speed in which they're closing as you work as a team, right, to capture and then you're cutting. Those things are important for a nice, efficient resection too. Oh, yeah. For sure. Ryan, I think we're going to maybe switch. We're not getting quite as good a cautery here. Ryan and John are two techs today. They're both very experienced. We really rely on them to use their judgment. They've got a great sense of feel, not only about when they're initially getting a hold of the tissue with the snare, but then also squeezing it enough to get that effect that we want of tight snare closure so that we get a pretty rapid transection. Again, I tend to focus on the most important thing to limit thermal injury to the submucosa, the deep submucosa being the speed of transection. You can get pretty rapid speed of transection using forced coagulation current. Now, of course, now we're using soft coagulation current. Again, I can't say that enough. Anytime you switch to the snare tip and you're using the snare tip, you want to be on that low voltage soft coagulation current. The goal here is to get the margin burnt on 100% of the perimeter. One of my things that I see with TSAs, TSAs I think are a little bit scary, but we seem to see a higher recurrence rate. I don't know why that is and I don't know if any of you guys have seen that, but that's been our experience. If it's a TSA, I always encourage people to come back at six months, but I respect these things. I never look in the data. Maybe you're right. Yeah. I don't. I could just be my anecdote. Should I revulse that little bit right there? What do you think? I've got to- It's a vessel. Okay. Let's talk about that. We see these vessels in the base right there. We've got two randomized controlled trials of cauterizing these vessels and both of them showed that it did not produce a statistically significant reduction in ... This would be like cauterizing that stuff that's on top of that vessel. It doesn't work to actually reduce the risk of delayed bleeding. I don't do it, but I will if I see an artery. The arteries are usually very small. If I see an artery, I will pretty much always cauterize that and then try to get one of the clips over it. I'm going to revulse that. Yeah. Doug, you are expected not to close with the clip this lesion because we are in the left colon and there is no evidence that we should clip left colon lesion. Am I correct or I'm missing something? I agree, Cesare. What I'm going to do in this case ... Close that, Ryan. Notice how I got the forceps just overlapping the tissue. I'm not grabbing a huge amount of submucosa. Then I tent first and then I just tap. You can see it peel off with the hot forceps. Okay. Now- I have a question on that too, Doug. You're just snare tip self-coagulation or ablation of the periphery. We're not doing the ulcer bed. Even if there's a vessel, we're just treating arterial and such. If you can restate that, there's been some questions in the audience about if you treat the ulcer bed, the defect bed. We don't treat the bed, no. The only time I would treat the bed is if I see actually an artery. You will sometimes see arteries. They're very small. They're usually white and they will kind of ... You'll see them pulsating. That's how you know it's an artery. If it's not bleeding at the time, I do like to treat those. That's just my anecdotal impression. The reason I think that it doesn't work to cauterize the veins that you see in the base of the defect is that they're not actually the vessels that bleed. Do you guys need the light on, John, or are you okay? Here's what we're going to do, and I want to get your take on this. This lesion's in the left colon. It doesn't meet our criteria for clipping. Now, I think there's two reasons why clipping probably doesn't work, not really proven in the left colon. The first one is that the background rate of bleeding in the left colon is low. The risk of hemorrhage is smaller. It's harder to show a difference between your treatment group and your control group when you have a low rate of the outcome in the control group. That could be part of the problem. The second one is that a lot of people think that because the left colon is narrower that it may ... The clips may not stay on as well. That hasn't been well studied, but we know that clips come off, and so that could be the reason. We are going to close this, but we're going to close it with a through-the-scope suturing device. You can see this coming out right now. This is the Boston X-TAC device. It consists of four metal tacks with a helical screw on the end and a suture that is running through these tacks. What we're going to try to do is bring this side of the defect over here, then I think we'll go back here and come over here and close this. Part of the reason we're doing this is exactly what Chessiree said, we're in the left colon and we could leave this open because the evidence is that the risk of bleeding is relatively low. But let's say at this patient, I would be fibbing if I said that this patient was on anticoagulation, he's not. But if he was and we, because we don't have a lot of data, we wanted to close this to reduce the risk, we could consider here this tool as a way to, let's go ahead and start the talk. Doug, what are your thoughts about some of the hemostatic gels which are available? Would that be a reasonable thing in this or do you just do them post ESD? When do you consider those? So I think that the hemostatic gels are brilliant in a way. Okay, I'm going to pull back just a hair and then put another full turn in, Ryan. Okay, and we'll deploy. Okay, there's our first tack. And now that's going nicely. And what we don't have, I think, Pratik, is we don't have evidence yet with the gels, you know, that they can really prevent delayed bleeding. For the most part, we don't have a strong reason to think that their benefit is going to last for, you know, 10 days, two weeks, the kind of bleeding period that we have when we have not large non-pedunculated lesions. And so that, I think, is the main problem. So I'm in normal mucosa here, pushing in. Ryan, you go ahead and screw the tack in. Once we get the tack fully in. So how far away from the resection margin do you usually go, a couple of centimeters? No, not a couple of centimeters, that would be a bit far. But usually several millimeters, yeah. And yeah, go ahead. I'm interested in other thoughts about this. Yeah. Very nice. How much big defect can you close with each tack? I think with one X-Tack, you can close a defect on the order of about four centimeters or so in diameter would be my own experience. Now I don't know if you guys can see in the room here, but at this stage, I actually have two techs helping me. Ryan is here and also John is over from the other room. And I'm trying to decide where I want to put this. It's kind of a funny shaped thing. I think I'm going to go, I think I'm going to go about right in here. Doug, do you want to comment too, just in terms of closure, but this is more apposition and in terms of you're not really getting anything across the submucosa or the vessels in terms of delayed bleeding. You're really just pulling the mucosa over the defect if you want to comment on if that would change your decision of using X-Tack versus clipping. Wait, wait, wait. OK, now go, Ryan. Yeah, that's a really good point, Tanya. OK, go deploy. All right. So, yeah, Tanya, your point is very well taken. And all I can say is that the observational data is that this works. Now, the reason I my theory about why it works is kind of the same as when you're using a closure clip like the mantis clip. We pick up usually with the mantis, we'll pick up the normal mucosa on one side of the defect and drag it over. And we don't really have the clips deep in the in the base of the of the defect like we do with standard, OK, Ryan, with standard hemostatic clips. So but it could be that if bleeding starts, is that going in OK? Try there. I feel a little bit careful about talking and working at the same time. You're fantastic. You're fantastic. OK, go ahead there, Ryan. We usually will put an extra full turn in with each tack. OK, let's deploy. OK, and now we'll pull the defect together. So the way the defect is tented, you know, if there is bleeding that there's some clot formation that I'm just going to back away a little bit here and we're pulling the funnel out now and then we're going to put the cinch down. And we usually try to keep some tension on the suture as we do this so that we don't have to drag the suture if the if the tacks are all sort of separated from each other, then it can becomes a little difficult to pull the suture and the tacks together over a significant distance. And so we keep a little bit of tension after we get the second tack in to keep the tacks relatively close together. And then it's a lot easier to pull everything together. So John and Ryan are keeping some tension on the suture. And now I'm passing the cinch down. Now this cinch is the same cinch that is used in the overstitch. So I'm back away from the defect a little bit so that I've got some room to get the cinch really close to the tacks. And now Ryan, you go ahead and cut the suture. And you get it all away. And it looks like it's going to take John's muscle to get that off. Or it might be off. There it goes. Okay, so there is our is our closure. And but again, you know, we have pulled the edges together. And not really, as Tanya was saying, we don't really have direct pressure necessarily on all the vessels in the base. But the observational data is that it works. So I presume that there's some other mechanism like what I was proposing, we'll need let's get a basket real quick to get the rest of the pilot. And that accounts for why it works. But again, we don't yet have randomized controlled trials. What we have so far are observational data about the the benefits. But I do think it's an option for you, especially if you would be closing in the area where you know, the benefits of clips are not well established like this, where you know, we're in the left, left colon. You can open the basket, Ryan. And would you trust it for a perforation? Would you trust to cross a perforation with the X-tack? That's a great question, Cesare. I wouldn't. I definitely would not trust it for a perforation because with a perforation, you know, we've got to have a seal. We got to have that hole very securely closed. And that it would not be adequate for that. So you know, a perforation, I would definitely prefer clips. Or if you have the ability to use full thickness suturing, that would be okay. But not this kind of suturing, which is not full thickness suturing. I would not use it for a perforation. Daga, you said that you are obsessive compulsive. How much are you obsessive compulsive in retrieving all the pieces of EMR? Because you know that Yutaka Saito argued that we remove big poly, but we don't retrieve all the fragments and there is a cancer in the fragment that we failed to retrieve. How are you sure that you retrieve all the pieces? Yeah, no, I love this question. I do think that we have to be pretty obsessive compulsive to get all of the pieces out. And I think it's even useful to count the number of pieces that you take. Check how many have come through the, into the trap. Check how many you're retrieving in the basket. Having said that, I will say that, you know, we, in about 7,000 EMRs in our database, we have had three cases where we've come back at six months and had a recurrence on the site that was malignant. And so, and in all those cases, you know, we had high grade dysplasia on the initial resection, but not cancer. So conceivably, we missed cancer or the pathologist missed cancer for this reason, but I don't think it occurs very often. And we don't see late cancers. You know, if we, in those seven, those very rare cases of cancer at the first follow-up, we have not seen patients come back, have a small benign recurrence or no recurrence, and then later see cancer develop at the site. But I think your point is well taken. You know, terminal resection from an oncologic standpoint, in several regards, is not as good as unblock resection. But you know, on the other hand, right now in the United States, we're not prepared to do unblock resection on all of these lesions. And I think, you know, today we're trying to get the message across of doing a good EMR, and I think the more people that we have doing a good EMR, that's a really important thing too, as well as recognizing when an unblock resection is needed and how to get that done, because ESD is not the only way to do it, as we've already discussed. I think we're going to break away now and go to the next case.

endoscopic mucosal resection

Traditional Serrated Adenomas

colorectal lesions

snaring techniques

X-Tacks

medical procedures