female who underwent colonoscopy at an outside institution for positive colgard in September of this year. There was a 20-millimeter lesion in the cecum removed by hot EMR, came back as sessile serrated lesion. There was a 4-millimeter lesion in the transverse colon removed by cold snare, came back as tubular adenoma. What we're left with is a 50-millimeter granular homogenous lesion in the proximal rectum, no biopsy and no tattoo. And the teaching point for this case is to demonstrate hybrid EMR. So we're going to go to Dr. Gardiola. Thanks Megan. So this technically is hybrid APC of an EMR. This is not actually, you know, hybrid EMR often refers to where we're doing like a pre-cut or some sort of, you know, mixing ESD techniques. But this lesion actually came out very easily. This area here was actually, I had a little bit of an arterial bleed and I grabbed, used the hot forceps and I just put it on soft COAG. I already had those out because I was cleaning up a few areas of tissue with a hot avulsion technique. So a few things about hybrid APC. So this is not the standard of care. The standard of care is still snare tip soft COAG. And APC is really, should not be used over STSC mostly because there's really no reason to in the randomized trial comparing STSC versus APC per margin ablation. You know, they had similar outcomes, but STSC is much faster, obviously much cheaper. And obviously you're already using the tool. So why would you grab a new tool? So the idea behind this is that we're going to use this catheter, which is both a water jet catheter and an APC probe. I'm going to go around like this. This is a high pressure, which is not working. I am using the fluid. I'm trying to get the, is the fluid running? Should be. The idea is that... John, what is the difference between injecting with a needle and injecting with this catheter? So really it's the ease of use, but also this is going to deliver a precise amount of fluid. So it'll beep. I don't know if you can hear the beeping, but it tells me one CC exactly. Also, what is nice about this is if you have a lot of fibrosis, it doesn't necessarily lift better with the needle, but it will find that submucosal space and allow it to at least stay in the area. So you can kind of get a better idea of your plane of... There we go. Okay. So that's what it's supposed to do. So I'm going to go around and lift the margins up. Nice raise there, John. And then I'm going to burn this. We use a lot for Barrett in Europe. Yeah. So, I mean, I think it's the same concept, right, Cesar? I mean, you saw the study. I mean, I think in your unit has that study on hybrid APC and Barrett. And I think the goal is just as John's demonstrating here is that you just protect the deeper layers by creating a cushion. It is important to protect the layer because the power of this hybrid is more than the traditional APC. So at least in Barrett, we really experience a deep effect of this technique. So we are very happy and satisfied with this technique. So John, what's the voltage of the APC setting that you'll use? For the margin, we will use 40 Watts and one liter. And then for the base, we turn it down a bit and use 30 Watts. Okay. And then like Barrett, I mean, do you scrape it off, do it twice or you just do it once? We just do it one time. So for the margins, you know, you want a nice, I try to get a nice burn. We're on margin, correct? Yeah. Turn me up to margin. I think the difference here is in Barrett, you're treating, you know, you're treating dysplasia. In here, you're treating the normal margins. So I think that's one point. And the second is, we, perhaps also the other reason is that the Barrett's guys are much smarter. That's why they do it twice. Well, that was already an existing assumption. Doug Rex used to be a Barrett's guy many years ago. I saw the light. But the idea of the injection is actually, John, as you remember, was a colonoscopy study, right? He just decided to, you know, do an upper on those patients. Yeah, exactly. Do you think the idea of the injection here is, as you guys are talking, to protect the thermal or, because this has been done for 30 years without injection. So I think also they argue that it allows you to better assess the margins when you lift it up. This is basically two observational studies where we have most of this data for this technique. I think it can help when you lift it up. Tanya, I think the other thing is that, you know, I mean, Doug was mentioning earlier about Michael Burke does the soft tip coagulation. He's much more aggressive than what we do here in the US to do it. I think this lift just allows you to do that in which you can be a little bit more aggressive and not worry about deep thermal injury. One thing too, is when you're doing the margins, see, I don't like that there that, you know, I feel like I kind of had a skip lesion and that might be where some of the recurrence is coming from. But yeah, Michael Burke is extremely aggressive and I try to be as aggressive as he would be. Don't be upset with me, but this technique look to me easier. I agree. It looks easier and it's more elegant. Don't take it personal. You're talking about this versus STST? Yeah, it's just prettier. Cesare, are you trying to say that John's doing a better job than Doug? Is that what you're saying? So we need to go by the data, guys. Again, I mentioned that the standard of care is SNARE-TIP-STOP-COAG. This, and we need more randomized trials, which, you know, Dr. Van Relton is leading a randomized trial here to compare this. And, but, you know, I mean, Michael Burke wrote an editorial really slamming this technique and saying, you just need to be good at EMR. You don't need to do all this fancy stuff. So. So I think this is an important point that, that this is, we're showing something here for the first time that is clearly something that you shouldn't necessarily try at home. I'm not talking about the margin treatment that John's been doing for the last couple of minutes, but rather once we go into the base of this defect, we don't have a randomized control trial showing this. I personally worry that when people start treating the base with thermal injury, there's already thermal injury there, that we're going to, we're going to see some either post-procedural discomfort or delayed perforation associated with it. So this is a, this is a new technique. I know Daniel was talking about this during the break, and it may prove to be very important, but I would just say, be cautious about this. We've slipped into the, an area that I would view this as don't try it at home. And I would just say that with regard to the margin treatment, STSC versus APC, in the only randomized controlled trial comparing the two, not only was STSC numerically more effective, but actually it was faster to apply than APC. So and you know, APC catheters are not cheap. So there are multiple upsides to following the evidence when it comes to margin treatment. We'll go ahead, Cesare. I'm sorry. You said that with STSC, the risk of recurrence is now 5% or even lower. How much low should we go? What is the clinically relevant for our patient? Are you looking for a 0% recurrence rate after EMR? Well, that would be nice. I mean, you know, if we had techniques where we could reliably get that, then, you know, we could potentially change our follow-up strategies and, you know, because our classic follow-up strategy is six months, 18 months, and then three years after that, and then we finally we get to five years. But, you know, when we get down to recurrence rates that are seen with on-block resection, then we have the potential to go straight to a year or and eventually, you know, even longer. So I think, you know, the long-term benefits of very low would be good. And I think that's part of the idea here is that, you know, what John is demonstrating right now, this hybrid EMR technique, that if it does get us down to 1% or something, you know, it could have some important implications because, you know, people earlier, you guys were worried about people that don't come back. And, you know, when you have a very low recurrence rate, you don't have to worry so much about people that don't come back. So I think the long-term goal is an important one. And what I'm doing with the base is, if you're wondering, like, how far to go, really, it's really just this contraction of fibers that you can see kind of happening. I don't really seek to char the base. I think John Levenick at Penn State is a little bit more aggressive maybe, but Daniel Monterell doesn't does not really char the base. And I think that's one of the problems is we don't really know right now how much to burn it, you know, or we're talking about burning the base and people are sort of doing different things, but I don't think you want to end up with the same brown char that you got on the margin. Why don't you blab again? Why don't you alternate fire and blabbing? Honestly, because this wasn't that big and I just kind of did it that way. I like to just do one thing at a time. And if I can get by, yeah, no specific reason. It's just kind of my approach to it sometimes. Because when we do for Barrett, we try to fire only on the blab, not on the non-lifted mucosa. Yeah, good point. Yeah. I mean, even in Barrett's though, we don't really have evidence that it's critical. Do we critique to inject? I mean, we, you know, going back to Dick Sampliner and, you know, 25 years ago, we used to ablate Barrett's before we had RFA using APC and we, and we never injected those people. And, you know, we would see a very rare bleed, but you know, a deep thermal injury was, was extremely uncommon. So, I mean, I understand. There is evidence, Doug. I mean, I think so for, for, for Barrett's Doug, there is evidence. So, I mean, with the traditional RFA therapy, you know, even registry studies, RCTs show stricture rates about eight to 9%. And with this injection technique, the stricture rates are about 2%. So in terms of strictures, it does show that. And then the double treatment technique, you know, does increase your eradication rates and also decreases your recurrence rates. So that's the rationale for the double treatment, at least in Barrett's. Okay. Well, there you go. Yeah, Doug, the power in the esophagus is now higher. So we, we had one perforation with the hybrid APC in Barrett and we have quite a lot of patients who report pain after the procedure that lets us understand that there is a deep injury. So at least in the esophagus, you need to be very careful with the hybrid APC. Okay. So very good. Are there some questions from, from the audience that, that the panelists can bring up? I actually saw one pop up on the screen about glucagon for peristalsis. And the answer is yes, we do use that sometimes. We'll give you their 0.5 milligrams or one milligram during the procedure. Okay, John and Doug, I think that's about it. There, should we go to our next break here? John, nicely done and congratulations. Thank you. We really had a genuine surgery or life-saving moment with RDI in June 2021, where a colleague had resected a pedunculated polyp, and it had bled significantly. And the problem was that it was in a segment of severe diverticular sigmoid colon, very difficult to expand in a patient who was experiencing quite substantial discomfort during insufflation of air. So you've got a real difficult situation. You've got a patient who's in discomfort, a difficult segment to maneuver the colonoscope, and an artery's bleeding. And my colleague had tried for a period of time to try and stop it bleeding and hadn't been successful at that. He's a very experienced endoscopist. So he then called for my help and walked down to the theatre and walked in. And we had a discussion for a moment. And I said, well, you're in one of the rooms where we've got the uvis-x1. Have you put the RDI on to have a look and see if you can spot the bleeding point? And he said, what's RDI? And so I said, well, it's this imaging technique that basically separates the different reds and allows you to visualize the vessels. So anyway, so we nodded agreed and went back in with the scope and went up, turned the RDI on where we got to the pool of blood. And you could see the spurting vessel in the middle of the pool of blood that was completely invisible on standard white light imaging. And then that allowed us to get a clip down through the scope straight onto the point where the bleeding was occurring, clip, bleeding stopped, all done. And so after quite a stressful 45 minutes of trying to stop the patient's bleeding, we'd sorted it out in five to 10 minutes, just because it suddenly allows you to see where you need to treat. So I think this is a big field change in imaging and endoscopy. This is something that's going to make it more possible to be successful at treating GI bleeds, simply because you're not treating it blindly. So I think without RDI, in the case I've described, it would be very likely that we'd have tried to go back in endoscopically and spent a lot of time washing the area and trying just to find where the bottom was. We might have even sort of thought where it looks like it's roughly coming from there and put a clip on that out of hope that you might be able to stop it bleeding. But ultimately, if we hadn't successfully stopped the bleeding endoscopically, the patient would have been brought into a hospital bed and sort of maybe given some tranexamic acid and medical treatment to try and stop bleeding. And if it became evident that it wasn't going to stop bleeding on its own, the patient would have ended up having surgery, which would have meant potentially a stoma, a sigmoid colectomy at least, or a segmental resection of the sigmoid to remove the point where it's bleeding. So the implications for the individual patient of not successfully endoscopically controlling it were massive.

endoscopic techniques

APC and EMR

colon lesion treatment

RDI imaging

patient safety