We will go to our first live case demonstration to Dr. Doug Lekrex from the Indiana University. Dr. Lekrex, you're live. Thank you. My chief fellow, John Guardiola, is going to present the case. So, this is case one. This is a 21-year-old female with FAP, otherwise healthy. She has a very heavy pancolonic polyp burden, substantial rectal polyp burden, but not carpeted. Surgery's planned. Patient was offered a total proctocolectomy with an ileopoietinol anastomosis versus a subtotal colectomy with preoperative endoscopic clearing of the rectum. Important thing was to maintain her fertility. In June 2022, she had a lower half of her rectum was cleared of polyps with cold snaring, 43 were removed from 2 to 18 millimeters. The plan today is rectal clearing and tattoo at the proposed surgery site near the rectosigmoid junction. So, thank you, John, and hi, everybody. We are having a bit of a transmission problem, so we can't show you the room view, but I'm hoping that the endoscopic view is pretty clear. It allowed us, when we cut the room view, to get a clear endoscopic image. So this is a young woman who basically decided that in order to maximize her ability to get pregnant, her fecundity, that she would like to preserve her rectum, and I think also from a quality of life standpoint. So I guess there are a couple of things to discuss about the case that are of interest. One is the approach to FAP like this, because we have the options of ileoproctectomy versus a subtotal colectomy, and the second one would be cold snaring and sort of what are the limits of it. So I'm starting here in the distal rectum, and I saw this young woman about three months ago, and I cleared her distal rectum at that time. You can see that all the polyps are pretty much gone. I did find one polyp in this region this morning, and then I'm moving up into this section, which is, Ryan, if you'll give me the snare, which is a section that I've been clearing today, and I think we've taken about, how many polyps is it at this, we've taken 71 polyps out of this section, and we're moving up toward the rectosigmoid junction, and I want to say that a lot of these polyps were quite large, and many of them were pedunculated. You can see as we get up toward the rectosigmoid, the number of polyps that are, you know, pretty good size. This is pretty much how the rectum looked. So one of the advantages of doing this cold is that it's pretty much devoid of complications, and that, of course, is a great thing when you have this number of polyps, because you can, you know, basically, if you took all these open, if you took all these out hot, the risk of a bleed from an individual polyp would be quite low, but the risk, you know, with hot snaring from this number of polyps would be, close and cut, would be exceedingly high, I think, you know, 150 or so polyps in one session, close and cut, and also it's just a lot more efficient to do this cold. So I'm getting close to the, we started the case about a half an hour ago, and we're getting close to the rectosigmoid junction where I'm going to put the tattoo on, but I think I'll take out a couple of these larger lesions up here, open right, and we're using a dedicated snare, closing, and cutting these cuts, and cutting them fairly close to the base, and we'll get a little bit of bleeding. It's my intention to probably not use any clips, that won't be necessary because of the open, because of the cold resection, close and cut. Doug? Yes. Hey, Doug, it's Prateek, how are you? Good, Prateek, how are you doing? Hey, excellent. Listen, so, you know, great job in showing us, you know, those quick snares that you're doing. I saw you cold snare even a couple of really diminutive polyps, one to two millimeters. I mean, there was this recent study showing that a forceps was similar to do that. Any comments on that? I mean, would you continue, you know, cold snaring even those really, really diminutive polyps, or do you think we could do a cold biopsy and remove those too? That's a good question, because I know forceps are still commonly in use. In this particular case, Prateek, open, it would require me to switch instruments. I actually think it's generally more efficient. I'm going to pull a couple of these out just so we can see better. We've been delivering all these patients, these polyps out the patient's rear end as we're going. So the studies that you're referring to, Prateek, including the recent one, they showed that, you know, a jumbo forceps has similar efficacy for polyps that were up to three millimeters in size as snaring, and maybe a little bit more efficient. I kind of think the efficiency factor that there's some variability in that from endoscopist to endoscopist, I find it just as efficient to use a cold snare. And so in the general setting where you see polyps that are three millimeters and smaller, then I think that using a forceps, especially a large capacity, like a ring or a jumbo forceps, is okay. But above that, once you get to four millimeters, then you really should be using a snare because a snare is more effective in getting the entire polyp out. And so we are using, I know Heiko is going to talk about this, he may be on the line, but we use cold snares for everything that's a centimeter and smaller, all of the serrated clasps of lesions, and also a lot of pedunculated lesions, which is interesting because I think traditionally, you know, we tend to think of pedunculated lesions as things that are, you know, there's such a risk of bleeding, but I think it's kind of a nuisance. It's not as fast to take them out hot. You have to be careful about controlling the burn. And my experience has been, and here we're, you know, we've got some polyps here that are up to probably, I think that's already been cut off, looking very purple. Let's see if that's going to come. Right. And Doug, great point about not just the efficiency, but using multiple instruments. So you're right. I mean, if you have one instrument out, you may as well just use that rather than using multiple instruments for these polyps. Yeah. Yeah. Yeah. I mean, HICO is leading a task force, a multi-society task force about, you know, things like plastic waste and our carbon footprints. And so when we can sort of limit instrument use, that's nice. But it's also, I mean, my number one goal usually is just efficiency. I want to be as efficient as possible. And I know I'm going to, in many cases, I'm going to have a snare out for a larger lesion. So I just prefer to get to use it for a smaller lesion also. So yeah. So good point. This, you know, in FAP, I will say that I think this is very feasible if you want to save the rectum, except when the polyps are confluent. Every once in a while, you'll see somebody that is as a virtually confluent appearance to the polyps. And go ahead and cut, Ryan. And when you cut cold, you do get scarring. And you will, if you virtually do a complete mucosectomy of the rectum, which is, you know, really extremely difficult. So we've got some bleeding here. So I'm just going to pump a little bit of water into the submucosa. I think you get less bleeding if you cut close to the wall first. And secondly, if you give it a squeeze. I'm not really doing that because I'm trying to be efficient. But in the setting where you've got one or two that you want to do it on, grab the stalk and squeeze the base for about eight or 10 seconds. Open. And you'll tend to get much less bleeding as you transect. Doug, as you're showing that nicely, there are a couple of questions all on the same topic about pedunculated polyps and cold snare. I mean, is there a size of the pedicle or the stalk at which you will not attempt cold snare? Yeah, yeah. The stalk is really thick. I would say, you know, it's an individualized decision. But it's really thick, Doug. Well over a centimeter or bigger. I think I, you know, it's hard. At some point it gets hard to mechanically transect. And so I probably would at that stage go ahead and use electrocautery. Always force coag current. Always get low on the stalk. We're going to, so I think we need to wrap up here to go to another case. We're going to take out a few more polyps and then we're going to tattoo here at the rectosigmoid junction. And as a marker for where the surgeon will do the transection of the colon for their subtotal colectomy. And I will cut loose so you guys can go to the next case. Open. Thank you Dr. Rex for this nice demonstration.

familial adenomatous polyposis (FAP)

surgery options

preserving fertility

cold snaring technique

tattooing rectosigmoid junction