A 66-year-old male underwent colonoscopy at an outside institution for a positive PET CT scan in September of this year. There's a 20-millimeter penunculated polyp in the sigmoid colon removed by hot snare and came back as tubular adenoma. There were 10 penunculated sigmoid lesions in the ascending transverse and sigmoid colon. There was a cold removed by cold snare and they came back as tubular adenomas. There was a 25-millimeter sessile lesion in the hepatic flexure and it was partly removed using hot snare and it came back as tubular villus adenoma. And the teaching point for this case is we are gonna demonstrate tools for successful resection of lesions that have been previously partly resected. So we're gonna go now to the case. Thanks, Megan. Can you guys hear me now? You okay? Yes. Okay, good. So we are at the site of this lesion. It's in the hepatic flexure. This area down here, if we look at it in blue light and with close focus, you can see that the pit pattern on these bumps is that nice circular round pattern which is really the same as the normal mucosa. If I look over here at the normal mucosa. And so this is what we would call mature clip artifact and that's not adenoma. And then when you have a retained clip as we have over here, it's very common to see some inflamed tissue around the base of that clip. Try to look at it in TXI. So that, however, the pits are round still. They're bigger than the normal pits. So inflamed pits usually will keep their fairly round or ovoid shape. They're not tubular. So this clip, as is the usual case, does not have residual polyp around the base of it. And then there is quite a bit of scar. And then this is the residual lesion. So one thing I really like about what the referring doctor did here is that they sent the patient to another endoscopist to remove this. I think one of the things that people sometimes do in the community is they think that if for some reason they stopped and they can't finish the resection that the patient should be sent to surgery. And we have to remember that surgical resection is associated with considerably higher morbidity. There's a 15% readmission rate for hernias, et cetera, within the first year. There is a mortality rate that is substantially higher than endoscopy and there's much greater cost. So a bully for the referring doctor that they didn't give up. I mean, obviously they ran into some concerns, something that made them stop the resection, but they referred the lesion on for resection. Now, if we look at the distal edge of this lesion, you can see that there's quite a bit of scar tissue there. There's a tiny little adenoma that actually is adenoma down here. I don't know if that's like a separate adenoma. I don't think it's part of the recurrence. And then up here, of course, we have the typical pit pattern of an adenoma. I think everything here looks benign. Probably we have scar tissue on about 40% of the circumference of this lesion. So we have a partly resected adenoma. And I would like to pull the panelists and ask them what their approach to this would be, or maybe I should say what the possible approaches are to removal of this lesion. Yeah, I think, Doug, what's interesting, like you point out, this is more on the backside of the fold. So it may have become more difficult for the referring doctor, what you were saying, how they stopped. And I think you're considering location, scar tissue, I would personally see how it responded to the lift. I would put the needle right in that divot, right by the spot that it's about to bleed. Like, yeah, and then I would look down as I inject it and then see how much this lifted up. But you don't want to inject too much at first because you want to just see what happens, right? And then depending on that, either snare or if it needed, and sometimes in these cases, if you were needing to do like a hybrid using a knife or such. But I think my first assessment after seeing that there's no looks of submucosal invasion would be to inject a little and see the response to that. Okay, that's very interesting, Tanya. Thank you, appreciate that. I'm gonna take a little bit different approach and I'll explain myself, but any other thoughts? I know that there are people that would remove, it's not a very big lesion. Some people would come up here with a full thickness resection device and take this thing out. And we have tools like the endo-rotor, which are for like slicing up polyp. I personally do not, I have used that, but I don't use that in practice with any routine. Now, I think my reaction, Tanya, would be that if we inject here, we just not going, it's not going to lift. So there's no hope there. So, and the other thing is if we inject it here on the anal side of it, we might push it back on the other side. So I think my preference is a needle into the patient. I think there's a chance that it will lift on the cecal side. And I'd rather put the fluid over there and turn the lesion up toward me a little bit. So if it's okay, I'm going to try that injecting. And I don't even know if that will go in, but let's see, there it's starting to go. And you can see it's turning toward us a little bit, not great, but some. And not lifting great. And as we'd sort of expect, needle back. Now, I do think underwater here is one consideration. And needle into patient. I will sometimes do kind of a hybrid thing here. Go ahead, go ahead, Cesare. Did they tattoo the lesion? Did the previous endoscopist tattoo? Yes, yes, they did. Because I feel this was an error. If you think that another endoscopist is going to do resection, I understand to leave a clip, but I would not like to have a tattoo because it give fibrosis. Actually, let me put a little bit. Yeah, okay, so needle in the patient. You would rather just that the lesion is not tattooed at all if the patient is going to be referred for resection. And I see your point. I've heard, needle back, I've heard other people say that. The one thing I like about the tattoo, and this maybe does, let's go to the 15. Maybe it doesn't really make sense to me, but we see so much synchronous disease in these people that when we go into them, I oftentimes feel like I can't remove it all in one session. And so I will tend, I kind of want to know what the lesion was, which one the doctor wanted us to remove. Good point. It helps me get my bearings on the case. But I hear what you're saying. And we see a fair number, for example, of lesions, even in the cecum and proximally ascending that are tattooed. Let's open the snare. Now, go ahead. So Doug, since Heiko is doing a lot of the 20 millimeter above studies, I'll refer some of those to him. And what I do, I think tattoo is okay if you describe where it is and you are five to six centimeters away because there is tracking of the tattoo. So I like tattoo because it does tell you where the lesion is. As long as you describe it, you photo document it, and you make it very clear where the tattoo is in relation to, and you make sure that you're far away so there's no tracking. Yeah, I hear what you're saying. But if you go in surgery, you realize how far the tattoo spread. So even if you do five, six centimeter, it can counter the lesion. And then it causes fibrosis. Anyway, very nice resection. So you can see here in the base that we've got nice semicostal staining over on the right side, the distal side. On this part over here, we don't really have much of anything. Could I have some avulsion forceps? Now, one thing that's a little bit tricky is to know, you can see the fibrosis, I should say. It's a little hard for me to hold this position, but right there in the base of the lesion, you see that whitish part over on the right side of it, that's fibrotic. I actually think that I probably got it all because when I placed the snare, I had a reasonable amount of normal tissue that we cut through. But if I have any question, I'll use the hot avulsion technique. On the edge that was scarred. So, open for a second, Ry. So let's say that I've got, I have some question about tissue on this margin. And I'm not saying I don't have some question. Like, let's say, what is that? I don't know. Close. Anything that I think might be residual, grab it in that mechanical tenting, and then pull it off. And it just helps clean up. And then the other thing that we'll typically do, open, is to, open all the way, Ry, and I'll see if I can get rid of that. Maybe not. Sometimes we try to get- Okay, what about cold snaring for recurrence? We do a lot of cold snaring. We will have done this one, cold snaring. Really? Yeah, that's impressive. Close. I think you're more coordinated, you and Al, than I am. I have a really hard time with the fibrotic part when I'm trying to do things cold. I find that the snare tends to bounce off. You can take that, Ryan. It tends to bounce off of the, I'll take the snare tip now, if you would, and we'll go to soft coag. What is the, do you then, do you then ablate, or do you apply heat after you do that with the recurrence ones? Are you talking to Chesiree now, or me? Either. If you're gonna do cold to a recurrence area, do you then apply heat after? Yeah, well, I do think that if you're doing a cold technique, Chesiree, you could probably describe it. I find that you get away with it sometimes with a recurrence that doesn't have a lot of fibrosis, provided that you really deflate a lot and you manage to get the snare to really sort of sink in into the normal mucosa. But I often find that when I'm using a cold snare in a fibrotic area, that the snare tends to slip across the fibrosis and move right up to the very edge of the polyp where we get some cooks. So, usually what we do is we take the polyp very deep and then we close the snare and we have quite a lot of tissue. And in cold snaring, it doesn't close all. So after we squeeze the snare, we just come out with the snare slightly open. And this is sufficient for the snare to remove the scar tissue. Of course, we do this when the recurrence is very flat and you cannot suck in the cup as you did in this case. So you're saying you just cold snare and you're done. You don't do snare tips off coagulation or ablation after, even in a recurrence? Even in a recurrence. Yeah, I find that- That's hard to do, Cesare, right? I mean, I think it's like, I don't know, Cesare, your experience, but I mean, trying to treat these recurrences just by purely cold just is very difficult. Just because of all the fibrosis associated with it. How do you get over that fact, Cesare? I mean, because it's a post-polypectomy area, then scarring, fibrosis. Yeah, no, I mean, the problem is that you see that Doug sucked the tissue in the cup and he is not scared of cutting the muscle. On the other hand, here in Europe, we are a bit scarred to a hot snare after sucking the tissue in the cup. So we prefer cold because we are more confident not to cut the muscle. So our assumption for cold snaring is do not cut the muscle, as you may do if you suck and then you cut with the hot. Doug, there's a question from the audience of what did you inject here when you injected? What was your fluid? We used Everlift. We used Everlift as our main fluid. As you know, Tanya, from the document that you wrote, the MSTF, the value of using a viscous solution is that you have a somewhat longer duration of your injection mound and you can oftentimes get the tissue, the lesion out faster and in fewer pieces. Now, higher. Hey, Doug, in this situation, I mean, could you, just because you're dealing with the recurrence and you'll probably go back, have a look at it. Can we get away without clipping so that you're probably in a much better position when you come back in three months, six months to relook at this site? You might be right. And I don't know that we need to do this open. There's a thing called a type two muscle injury, which means that you're not really sure because you've got so much fibrosis or whatever. You don't know whether there's a muscle injury or not. First position, fire. Why did you choose the cook, an audience member is asking? In this case, because of the fibrosis and just the size of it, the cook clip is a little bit bigger. So I decided to use a clip a little bit bigger and strong arms, because I wanted to push on it and try to gather up that fibrotic tissue. But it's open, it's not a huge deal, same angle. And so I hear what you're saying about clipping and leaving it open. But the truth is because we used cautery, first position and fire. So I'm guessing that the reason that you did it was more because you were concerned about some muscle injury, right? I mean, my thing is that if you're dealing with recurrences, and again, I get your point of why you were doing it, but in an otherwise post-recurrence area, I mean, I tend not to clip it just because you're gonna go back if there's further residual tissue, it just makes it difficult. But I hear why you're doing it in this situation. And I appreciate that. And I think it's an area that we don't have, in general, optimal treatment of recurrence, whether or not to close. It's not something where we have a lot of data, right? So, okay, I think we need to break away now. And I will see you guys shortly in the room next door. Thank you. Maybe Pratik, thank you. I think there's lots of questions about cautery settings and also about like what tools are used for the avulsion, whether it's the hot biopsy or certain, that may be something that we address at the end, because it seems- Yeah, or it's a good point, Tanya. I mean, I think one of the message we can see here is that there are different practices, different ways of doing it. And as long as you become proficient in one technique, one snare, whatever it is, your favorite one, and just keep practicing that, I mean, I think that will be the key. But yeah, Tanya, we can get to it at the end. I think now we're gonna go to a break, a commercial break, and then go to the next room. ♪♪ It's exactly the point. Like, we all started the margin ablation, and we had these improved results with regard to recurrence rates. And so a few years ago, we asked, why are we only ablating the margin? Should we also continue and do a prophylactic base ablation? And we're using this technique since about two years in Montreal, now across two studies with more than 300 patients done in the last two years, and with recurrence rates in the range of 1% to 2%, and also very, very low complication rates using this technique. And I want to show a few cases, the very large polyp that was first inspected to make sure there's no signs of invasive cancer, and then we moved towards a standard SNARE-acute marrow resection because it just allows us in a very efficient way remove polyps without a sign of invasive cancer. So the standard injection, and I also want to say, like, we really inspected the areas where there could be visible remnants. So ablation is not a technique to do a sloppy EMR and then ablate just over it. Like, we really try to take care that the margins are clean, that the centers is clean, and then we can move to this ablation. And since we go for the margin-based, use this hybrid technique, which hybrid argon plasma coagulation technique, which allows us to inject and, again, lift everything, get these capillary bleedings to stop. So we get a very good inspection of the resection site through that. And then you see here, I just go over the base. In that case, it's a 40-watt pulse ablation. I would, for the margin, I take always a bit more aggressive, like a 40-watt pulse. For the center, it's kind of between 20 and 40 watts or the size. And I re-inject here and really get a good view and get a good view of all the areas. And I find especially important are the zones where you see these straps overlapping after EMR, and I target these areas specifically until I have a complete margin and base ablation. The only exception is if there is muscular shining through. So if there's already a deeper section exposing muscular layer, I would not ablate on that. But apart from that, I really try to do one complete base and margin ablation. And what we see when these patients come back, that same patient, this large melanoma, the scars look very clean. Interestingly, our complication rates, they're right now in the newest series with 200 patients, 1.7% in delayed bleeding rates that we experience using this technique.

colonoscopy

polypectomy

tubular villus adenoma

endoscopic resection

argon plasma coagulation

recurrence management