All right. So this is case three. We've got a 50-year-old male who underwent first colonoscopy at an outside institution in August. There were two lesions, each one and a half centimeter in the descending colon. They were hot snared and the path came back as adenomas. A one centimeter lesion in the sigmoid was removed with hot snare and also came back as an adenoma. There's a three to four centimeter lesion in the right colon, and there was no biopsy or tattoo placed. And the lesion appears to be an SSL based on color codes. Hey, everybody. We're back over in the other room. Here's the oleocecal valve, and here is this lesion. And actually, my initial intent was to demonstrate, because this was not biopsied. We did have a picture of it, and the picture, I thought it was an SSL. And honestly, I still think it's an SSL, but I will say that it's not your typical kind of real flat looking SSL. You can see some of these large open pits on it. The pits are pretty uniform in size, and the blood vessel pattern, if we go to a white light here, and I'll get off of near focus, is, you know, it's kind of lacy. It's not a typical adenoma. It's got a very irregular surface. And, you know, of the WASP criteria, it's got certainly the most prominent one here would be the irregular surface. The WASP criteria are a way of distinguishing between needle and hyperplastic polyps in injecting and SSLs. And, you know, so I got to say though... So Doug, you started to inject right in the center. Where did you, how did you decide to just inject there? Well, usually with an SSL, inject again, the best place to inject is into either sort of the middle of it or on the fecal side of it so that you kind of turn it a little bit toward you. Right. I will say there's an, so the first issue for me is I was, my plan here was to demonstrate, needle background, was to demonstrate cold EMR, but I'm not totally sure here that it's the right thing to do because I don't think this is our typical sort of flat, bland SSL. There's a lot of redundancy, Doug, is what you're describing, right? Yeah, it's a little bit bulkier. And, you know, I think it's going to be, if we do that, inject, Ryan, I think we're gonna have a little bit of a more likelihood of getting, you know, snare stuck a lot. And you wonder even, I agree with the beautiful pattern you showed about it being serrated with the O sign and the lacy vessels, and then that, that surface, you wonder some of the area to the right of your snare, not immediately right, but down like this, this may even be a serrated with dysplasia. Yeah, I agree. I agree. You look at, if you look at the pit pattern, you see the O pits, right? But the, where you see, the difference between HP and SP is often how symmetrical those patterns are. Like you'll have little circles, right? The type one, the type two pit pattern. Here, you actually see some more O pits and then you have, it's hard to see because there's so much movement, but there's a little bit of suggestion of maybe some adenomatous appearing, like type three or type, you know, three O or three S in the middle there. So I agree with you that there's dysplasia and I certainly would lift it as well. Yeah. Yeah. So I'm a little bit reluctant to not use electrocautery. I thought Prachik was going to be giving me grief again, you know, for, for doing another cold resection here. But in this particular case, although we removed the great majority of SSLs open, Ryan, with, with just cold resection, often cold EMR. Okay, let's close. I don't, I don't want to do it on this lesion. It's, it's redundant. It's bulky. It's got these features you guys mentioned. It's kind of red. It just strikes me as a little bit more likely to have advanced histology. And also it's literally thicker, you know, so one of the advantages of electrocautery is when you're trying to cut through bulk. So we'll go ahead and hit the cautery here and, and we're going to do with the endocata, Doug, that you showed, the endocata or no? Open. So I'm sorry. I heard Chess Ray ask about the current. Should I talk about that? Yeah. Okay. Yes. Endocata. So Chess Ray wants me to use endocut. And Chess Ray, why is that? Why do you want me to use endocut? I'm just asking. Probably in, in the proximal column, I guess that we are in the proximal column. I would feel safer with endocata. I would not go for, for squag. Okay. So I will say, I don't know if you can see Ryan in the room here, but Ryan has the snare almost completely closed and I'm getting through the lesion. I should sort of say maybe when I hit the pedal, I'm getting through the lesion pretty quickly in the transection when I'd taken the pieces. And let's have a little bit more injection fluid, right? That was my point about the injection is that, I mean, I think again, just for the audience, I mean, you could start a little bit more towards the sacral side too, right? Once you have had that raise or do it piecemeal, just as you've done is start more from the anal side, then inject a little bit more on the NBI findings. I thought that there were certain features also of like, maybe like a mixed pattern in which there may be some tubeless tubular adenoma features as well, along with the SSL. So I agree. I mean that this would be a good case to sort of like use current rather than just do it all. What are you injecting, Doug? There was a, from the audience, there was a question about that. We are injecting Everlift. This is a cellulose-based product. And I like it for one, it has methylene blue as the coloring agent. I find it to be inject. And I'm trying to, as I inject, I'm lifting the lesion toward the center of the lumen. Needle back. This lesion is as much bigger, you know, from the injection. That's one of the disadvantages of injection generally. I'm trying to check this far side and make sure, needle in, Ryan. It's adequately injected. Go ahead, Ryan. I was going to say too, as you inject, you can see your margins really nicely and the resection lines would be cut already. And you had sort of started making the point earlier when they were talking about current and your cautery, you have very little burn, even though you may have used the coagulation more. Doug, I think you were about to make the comment about it, but then. Yeah. So I will tell you that I hear what, first of all, I realized there's a lot of controversy about it. And there are a lot of experts, including Cesare, obviously, who use Endocut. I used Endocut for years, open. I rely really on the only randomized controlled trial that we have, which is the one, let's close now, Ryan, which is the one from the U.S. consortium. And in that trial, patients were randomized to get either forced coagulation current or Endocut. And the trial was interpreted as not showing any difference between the two currents. Open again, Ryan. But so here I'm putting the edge of the snare on the far side so I can see on the far side, so I don't, you know, you open all the way, right? We get to shake that snare a little bit. Okay, close again. So we got a little bit of blue in there. That's fine. We're just going to cut through that part of the submucosa again. So in that trial, there was no difference between the arms in the rate of delayed bleeding. That was the surprise, because everybody thought that Endocut would cause delayed bleeding. Now, if you look at, that's the only randomized controlled trial that we have. And open. Not really sure why, how I missed that, but. What about post-polypectomy syndrome? No, there wasn't any difference. And I tell you what, Cesare, the rate of immediate bleeding was significantly higher with Endocut, and there were three perforations in the study, and they were all with Endocut. I think. Go ahead. No, go ahead, Doug. I'm sorry. So I just think that, you know, if you actually look at the data, there really is not data to support Endocut for EMR. The data supports forced coagulation current now. Clearly, we were all using the ERBI units. These are microprocessor. Ryan, could you switch over to soft coag for a second? Are you on soft coag? Okay. So there's a little bit of slow bleeding here and maybe not quite the great thermal injury here. Okay. I'm just using a little bit of soft coag to burn up this area right here. And then I'm going to. If there is a visible vessel, do you treat it? If it was a visible vessel, if it was an artery, I would probably burn it first. There's a little bit of slow bleeding right down here. And anytime we're using the snare tip to control bleeding, we want to switch from forced coagulation current to soft coagulation current. Also going to get all the margins with soft coag. Yeah. So we're going to demonstrate that next. And I think the point about the Cotterie, Doug, is it's not just all or none. Like there's, there's many physics properties of how tight your snare is, how much of the polyp you are grabbing in the snare, how quickly you're stepping on the pedal. I think those are things that are misunderstood or not appreciated that transfer to how much heat you're delivering, which Irby's tried to control for more, but those are clearly variables when you're cutting a polyp as well. So, yeah, what Tanya is saying is that when you are, if you squeeze the snare, the tissue in the snare tightly before you hit the pedal, you increase the current density in the, in the snare dramatically. The current density goes up with the square of the radius or the diameter. I can't remember the formula, but that in and of itself will cause the transection speed to pick up. And it's really the transection speed on forced coagulation that allows you to have a, a rapid transection and keep this nice blue looking defect. It doesn't look really charred. Now that we used a little bit of soft coag to treat a couple of minor bleeds, and now we're doing this margin treatment with the snare tip. And I think that as I, as I watch people do this, something that's really important to emphasize is that we do it aggressively enough. We have to try to get the entire margin. And that may mean that we really have to kind of work to bend these folds back and get on, let's get a mantis clip to start here with. So Doug, while you're doing that, there are two questions about the setting. So what's your setting for forced coag and what's your setting for soft coag in terms of wattage? For forced coag we would use effect 2, max watts 25. For soft coag we would use effect 5, max watts 80. Now Michael Burke's original study was with effect 4, but I find we just get a little bit better burn when we have the effect setting on 5. So you gotta, you gotta look at your own machine and see what works best, but we're on max watts 80. Right. And I think that's the key is that always make sure when you go to the soft coag that you've actually changed the settings and you are on soft coag after you've resected the thing. And I was impressed that you still remember the formula Doug. So that was wonderful, but I'm with Cesare on this is that we also used, you know, we don't use forced coag, we use endocut to transect these polyps, but. Doug, if you did eat a cold snaring, would you have. Should I remove that? Let's get a convulsion forceps. So this clump of tissue right here, should I take that off or is it dead? I think it's burned submucosa, right? Like. I think it is. I think it must've had a cord because we had a little bit of, of, of delay on one of the transections, but I've got a little bit of obsessive compulsive disorder. And one of the things I think it's important is to go around the base and or go of the thing and make sure that you're all the way through the muscularis mucosa everywhere. Because if you leave muscularis mucosa, that might be associated with an increased risk of, of recurrence. So we're going to evulse this. And I agree with you, Tanya, and I have no idea if this is actually necessary, but now we are going to use endocut. So we'll be on the yellow pedal. We're going to use the, we're going to use, let's open that, right? We're going to use almost pure cutting current here. Close. And why would you evulse that instead of just using the snare? Cause you have that submucosa exposed right under it. You could get a nice, you used hot, you used cautery already. You could get a nice cut. I'm just curious. Why did you choose evulsion here? Close. Yeah, that's a fair question. I think I, I think I lacked confidence that I was going to get it with the snare. I've, I've prayed that the snare was, was going to not really take it very well. Okay. And what about cold evulsion here, Doug? Is it worth trying to, I mean, you're probably trying it right now as you're, right. You probably do need heat, right? Is that? You could, you could use cold evulsion. You could use cold evulsion and then use the snare tip to, to treat that. That's the cast technique, cold evulsion, snare tip. And so I prefer hot evulsion because it's cleaner. We don't have a randomized trial comparing hot to cold evulsion. But I would tend, I tend to use hot because the field stays, stays very clean. Doug, a great demonstration that we're going to switch and go to a commercial. So thanks Doug. Nicely done. Perfect. Thank you guys. 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colonoscopy

serrated sessile lesion

electrocautery

endoscopic mucosal resection

Everlift