Case nine, we've got a 57-year-old female with end-stage renal disease on peritoneal dialysis and underwent first screening colonoscopy in August of this year at an outside institution as part of kidney transplant evaluation. They found two large ascending colon polyps plus other small polyps. Our center, they had a colonoscopy in October with hot EMR. There was a 55-millimeter ascending colon polyp, extant closure, and tubular villus adenoma with vocal high-grade dysplasia. So now we're here for EMR of a second lesion, 25 millimeters located in the distal ascending colon. And we're gonna demonstrate evaluation of previous resection site, demonstrate retrograde evaluation and injection, and demonstrate EMR and closure. So now to room three. So hi again, everyone. We're in the cecum of this lady. She does have end-stage renal disease. Here's the appendiceal orifice, the ileocecal valve, and this is the site where we took off a large polyp just a couple of months ago. And you can see the X-tach is still in place. We've got a couple of clips on the site that are still in place. And I don't immediately see any sign of any residual polyp. So I guess one issue here is, should I remove both of these lesions in the same sitting? And that's obviously more convenient for the patient, but there's just a kind of a practical aspect to it, I guess, that drove me to not do it. The other, usually if there are two big lesions, we will tend to remove the larger lesion first, or at least the technically more difficult, get that out, make sure there's not cancer. I guess one rationale is if we take the first one out, it had some nodularity in it, make sure it doesn't have cancer, and then come back and get the other one, because if the first one has cancer, then a right hemicolectomy is likely to be performed. However, in this particular case, I will admit it was partly just the time taken. So this is a lesion, you can see part of it here, but I think it's a good one to possibly demonstrate the value of a retroflexed approach. So I'm gonna go back down in the cecum, and to perform retroflexion, I'm gonna, I think retroflexion a little bit more difficult with the cap on, but usually not too bad. And I'm maxed up and maxed left, and then I'm gonna roll over. And I think this is interesting to see, as is often the case, how much bigger the thing looks in retroflexion that we've got really quite a bit of polyp on the cecal side of this fold. And Ryan, why don't you put the needle out? I usually put the, if I'm gonna go into retroflexion, I usually put the instrument down before actually performing the retroflexion maneuver, because occasionally it's kind of difficult to get the needle to come out once you're in retroflexion. I'm trying to, I get a good approach here. I'm gonna needle back for a second. I'm gonna swing over to the maximum right deflection, and that looks a little bit better than maximum left. And so, uh, injecting there, Ryan. Okay. So now, once we get this thing injected, then we'll, we're using EverLift again here. And I like the concentration of methylene blue in the EverLift. I think it's a nice dark blue color. Needle back now. Uh, and we might unwind and take a look at the lesion in the forward view. Needle into the patient. Inject. Because sometimes all you need to do is the injection in the retroflex view. It's actually a separate polyp there. Yeah. And then once you've done that in the forward view, everything is pretty clear. And other times one needs to actually, you know, perform the, um, in the resection in retroflexion, you know, background. Now, I do think that, um, you know, when you're, we're talking about retroflexion, it's important to keep safety in mind. Retroflexion, I think in the literature, in the right colon, you know, has been an incredibly, inject, safe maneuver. Uh, and, um, you know, I would say you see more perforations in the literature from rectal retroflexion than you do right colon retroflexion, but I would be careful. That's very nice point. That's very nice point. I fully agree with you. Yeah. Needle back. But, uh, there is, uh, um, hey Britt, can you help her with fluid? Um, I do think that you want to be careful with a colonoscope if you're not in the right colon, needle end or the transverse colon or the rectum inject. So specifically I would be very cautious in the, um, you know, background. Uh, I would be very cautious in the descending or the sigmoid with a colonoscope because there, you know, back, there have been some perforations reported there and, uh, they probably, you know, the problem is you get into retroflexion in a narrow caliber, you may not be able to get out of it. Uh, now needle back. I think I actually am going to remove part of this in retroflexion here. Let's get a, maybe a 20, a 25 millimeter snare. While she's getting the snare, Doug, um, can you comment, the audience is asking like methylene blue. Can, can you comment on its usefulness in injection? So I think the methylene blue has, has several functions. One of them is the, uh, is the delineation of the, of the margin, of course. And I, I think that that's of greatest value with, um, with sessile serrated lesions, uh, compared to, uh, adenomas. Um, it has a couple of other important functions. One is the staining of the submucosa. We actually saw that really well in John's case, uh, yeah, you can open up there, um, because, you know, he took that polyp out, the one he just showed you the hybrid EMR on, he took that, uh, out, um, underwater. So he didn't have any staining, but then when he, uh, started to inject, okay, let's, let's close. Hey, Sean, anything, anything you can do that with, oh, she does. Okay, perfect, perfect. That's, that's great. I was asking, uh, close, I was asking my anesthesiologist. No, that's not, that's well, I don't think that's so great. Open. Yeah, yep, yep, yep. I don't like that too much. I'm going to go try to go the other way. Um. Does her end stage renal disease, Doug, change anything you do about like the, the, um, technique you chose or how much you cut? Not really. The main thing is I'm going to, I don't, I think this is not a good lesion for cold resection. First of all, bring that snare back just some, Ryan. Yeah. Okay. First thing is that, close, it's a large adenoma. So if we, if we don't use electrocautery for safety, um, we're going to have a higher recurrence rate. That's actually burning. Okay. Somebody turn the sound off on, on the, on the electrocautery unit. But what you importantly showed two times now, you were first left, um, dial, and then you went right to get a better position when you were like, and then in your snare, you completely redirected where you were coming from. Again, demonstrating to like, just take the time for the best approach, right? Yeah. Yeah. Tanya. Very, very good. I, I've using a big snare and I, you know, we often talk about snare sizes and, go ahead and close. I, I think I'm going to turn around the forward view here though, in a minute, cause I, I don't think I'm getting as much as I would like to get here. And so let's see. Vaga, would you consider a pediatric colonoscope for the easy retroflexion? It's a thought. Yeah, that's a, that's a thought. I like the bigger scope just to, cause of the channel size, mostly open. I think it's an advantage here. I see, I'm leaving that little area there. I don't really want to leave that behind. So I'm, go ahead and close. Great, I'm going to go behind there, but I'm kind of pulling the scope back into that. Take your time going through that, please. But I am certainly going to close this and we're going to give the patient prophylactic antibiotics because she's actually on CAPD. She's not a, she's on a peritoneal dialysis rather than, than hemodialysis. Now I feel like I have, I may be not well injected on the other side. Close. So I'm going to actually come out of retroflexion here for a minute. And let's look at this from the forward view and, and see what- How much do you feel, how much do you feel safe in a retroflexion? Do you also remove lesion in the transverse colon up to the splenic flexure? Occasionally, yes, Cesare, but I feel like the area that I find it most often helpful is actually in the hepatic flexure because the medial wall of the hepatic flexure, as you know, when you look at it sometimes in a retroflexion, it looks almost like the fundus of the stomach and it really can hide a quite large lesion. And so- Yeah, now you have a good, you have a good view now. Yeah. I'm going to put a little bit more fluid in on this side. Now I think that actually this is a very nice lesion for X-tach closure, which I don't know that we're going to have time to show that because we're, we're, we're quickly running out of time left in the course, but because we have to go over the top and grab tissue and then pull it back, I think that X-tach works very well, needle in now, Ryan, in this situation. What about the mantis? What about the mantis? Yeah, that, that might get it done too, Cesare. In fact, if we have time to show that, we can try that first. Needle back. Okay, let's go back to the snare now. And now, I don't think there's, I usually like to start on one side of the lesion and then progress systematically to the other side of the lesion. I don't, yeah, I don't think there's a terrible problem with starting on one side and then coming back to the other side. And I think that's what I'm going to do right now. And I'm also, I'm using a pretty big snare, I'm using a 25 millimeter snare, and I usually will only do that in the right colon if it's a granular lesion and it lifts really well. And I think this, this lesion has a really nice lift to it. So I feel like I open, I've got quite good separation. My snare is a little weirdly shaped right now, right, Ryan? Why don't we get another one? That's likely from the retro and you putting that pressure when you. Yeah, we'll just get a, we'll just get a better, a better snare. And then, but to meet in the middle, I, you know, I'd rather not do that. But I think if we do that, it's not the, it's not the end of the world. Hey, Doug, do we know what the histology of this polyp was or? So these both on biopsy, I think if the first one was biopsy, then I think showed either tubular adenoma or tubulo villus adenoma. But that's all. Why do you ask, Joe? This looks villus to me. That's why. Sorry? This looks villus. Okay. Yeah. Yeah. With high grade dysplasia, maybe. Yeah. Yeah. Close. So the pattern. High grade dysplasia. I think that's a good thing for the panel to maybe talk about a little bit. I tend to not have the slightest bit of concern about high grade dysplasia when I see it in a report. And we certainly would never, for example, okay, let's, let's go ahead. We would never like send somebody to surgery for high grade dysplasia. I literally see that happening sometimes in the community. Let's go to a smaller scenario. Also important if you're a pathologist for some reason, like you have intramucosal carcinoma or other language like that. Similarly, not that that doesn't reflexively take you to surgery. That's still all within the curative realm of endoscopic resection. So important points with histology. Yeah. So I think that point's really important, Tanya. Not in the colon. We don't have to worry about cancer in the mucosa. Correct. I was pushing, sorry, I was pushing this farther. Let's assume that there is a small area of submucosal T1 low risk cancer in this patient. Would you send this patient immediately to surgery or would you consider the fact that he has end-stage renal insufficiency, et cetera? So how many of the patients who come back with the SM1 cancer you send to surgery at the end? So I think traditionally that's, you know, been the approach. I think we're gonna have to get a 10 millimeter and cap that. Traditionally that's been the approach, Cesare. You know, the study from Michael Burke's group that was in Gut and Gibson was the first author a couple of years ago, you know, I think that's a really important study because what they showed there was that even in piecemealed resections, they could predict the presence of lymph node mets by either poor differentiation or lymphovascular invasion. And they could predict the presence of residual disease in the bowel wall open by disease that was with actually within a hundred microns of the resection line. Now I don't know how they get an accurate measurement of that in a piecemeal resection. I'm gonna use the cap technique here, trying to anyway, closing. I don't really have it up in the cap, but Ryan got it anyway, I think. There's one little fibrotic area in the middle. When you see some fibrosis, I think there's always a little bit, this is the area I like between my retrograde open, my retroflexed and my forward resection. And now these areas that are on the margin here, usually okay about taking those with a... Go ahead and close, Ryan. Do you feel that there was a submucosal invasion in this fibrotic area or it is only because it was on the fold? There was a slight depression on the big nodule of the lesion. I'm not sure. Let me ask you this. If you took that off, would you send it to the pathologist separately with snare tips? This was a good point. Maybe retrospectively. Yeah. Yeah. Maybe. Yes. Collegue, please. Yes, I would, Doug. You would. Okay. Well, we'll do that then. I do that sometimes too. I see this kind of fibrosis, it comes back, nothing, but... Agree. Okay. Maybe it's a little bit less out, Ryan. There you go. Now we're on snare tip soft coag. We've got a little bit of bleeding here and we're just going to stop that real quick. Okay. So let's get to the bulging forceps. Okay. Just while you're working, I was going to comment like initially that little section was hard for you to see, but when you snared the right side and open that up, then you got better viewing access too. Sometimes those things make a big difference. Yeah. So, okay. I'm going to follow the instruction here because sometimes as my colleagues are saying, an area of fibrosis will represent cancer and sometimes it doesn't, but we'll send it separately just to make sure it gets checked. I probably could try again with a snare, but I'm going to do hot avulsion here, open. And again, I put in the tip of the forcep, maybe not, you know, fairly close to the area. Now, Chesiree was saying, was noting that this is on a fold, close, open, close. Do you think so, Chesiree? It's on a fold? Yeah. The fold is risky for perforation too. The muscle comes up close under the fold. And okay, Ryan, now you can see that we just separated that tissue very nicely in the same plane that we were snare resecting in. Yeah. And so, so that's, that's nice. Now, right here, you know, we talked about this before in one of the resections, see this sheet, you see the white sheet effect that could well be intact muscularis mucosa. And if I'm going to get that, I got to do a little bit more avulsion. So I think that we're getting close. You guys can stay with me as long as you can here. So Doug, we have four minutes with you and then we'll have to go to our wrap up panel discussion and hopefully you'll be there. Yeah. It's likely that was scar tissue though, Doug. I mean, it nicely then everything opened up, didn't it? After you just took that off. Yeah. Maybe, maybe, but I'm always a little bit worried that it's, again, really nice separation open, that it's muscularis mucosa, let's see, open, Ryan. Oh no, this looks like you're, I really like what you've shown with the muscularis mucosa. Yeah. So what I, close there, Ry. So what I'm going to do here after you guys leave me is I'm going to do snare tip soft coag and then I will, I will close this open either with, either with, either with a mantis clip or with, with the X-Tac and, and then we'll, and then we'll be done and we'll, we'll try to catch, catch these little bits. You notice how I'm really cautious about how much I grab with those forceps. I mean, don't, don't just go hog wild with it, you know, just try to get the, the tissue here again, is that white sheet close and Tanya could well be right, but I do think that can be muscularis mucosa. So overall we're, we're in pretty good shape now. I think we've got a nice resection open and we'll do our snare tip soft coag. And very fast. I mean, you did in 10 minutes with the ESD, this will have taken two hours at least. So, yeah. Well, especially if, if I was doing it just right, it would take a couple of times. No doubt. This was a two hour procedure for what? For nothing at the end. Yeah. Okay. So I'll clean up a little bit. I'll let you guys, if you want to break away whenever you need to. They're telling me they've got one minute left open. Hey, Doug, is that residual right near that, that little edge there that, you know, that at the top. Yeah. It's sort of like seven o'clock now. Okay. Let me take a look, Joe. Yeah. Right there. It's hard to say the pit pattern. They're not right there in the middle there right now. There's so much art. Very good focus. The efficiency again, speaks, I think Doug's skills, obviously, but the teamwork, like he has a system. The assistants are, you know, they, they, they speak without speaking. That's really important for any of us doing this is, is who your team. Yeah. I appreciate it. I think that's probably okay, Joe, but I see that little slight change in pattern. Yeah. Yeah. It's a little different. You know, sometimes we get that chicken skinning next to the, to the adenomas and cancers and open just a hair. So. Doug, do you always use a cap? For instance, if you have a diverticular stenosis, do you do without cap? I, I, first of all, I don't find the cap to be as useful on the pediatric scope as it is on the adult scope, because the surface area doesn't allow the cap technique to, to go forward very well. I love the cap, especially on the ileocecal valve. So if we go down here for just a second and look at the ileocecal valve, I can use the cap to basically, you can see how I'm turning it toward me. Yeah. So on the, on the valve here, right now we're looking really basically on FOS into the valve. It's just dispensable on the valve. But for the cap technique, I think that it is a lot easier with the adult scope than the, than the pediatric scope, probably because of the surface area. And so I overall, but I would take the cap off if I have to get through there, there, just like you have to take the cuff off from time to time to get through the sigmoid. Occasionally you have to take the cap off and the cap. We'll have to move to our panel discussion and hopefully we'll see you in a few minutes on that. So thank you very much for that, Doug. Thank you so much, guys. I'll see you in a minute.

colonoscopy

end-stage renal disease

kidney transplant evaluation

polyps

retroflexion

fibrotic tissue