All right, we are going next to Dr. Gregory Haber from NYU. Welcome to NYU, and thank you very much for involving us in the course. We have a very interesting case, and I will turn to Ki-Yoon Kim, our advanced fellow, to introduce the case to you. Okay, thank you, Dr. Haber. So for our case today, we have a 65-year-old woman who had prior colonoscopy at a side hospital, who present initially with a 2.5-centimeter descending colon polyp that was tattooed on the opposite wall, and now present initially to Dr. Haber at NYU for evaluation and resection. The initial endoscopic evaluation showed cutopic pattern 2, Harris classification 0 to A, and the pathology showed traditional serrated edenoma, and then the pictures that you see below are our index colonoscopy with us. So the patient came with a biopsy showing a traditional serrated. We'll talk about that later, but go on. So Dr. Haber removed this lesion with piecemeal EMR with hot avulsion biopsy, as Dr. Rex mentioned earlier. This is back in January of 2022, and you see the resection margins after the piecemeal EMR as well as the hot biopsy avulsion technique in the picture shown below. And the pathology slide that you see below showed focal high-grade dysplasia and an intramucosal adenocarcinoma, and it's a self-serrated adenoma without any evidence of submucosal invasion. And follow-up colonoscopy in May of this year showed post-EMR scar in the descending colon, again, marked by the tattoo on the opposite wall, and the biopsies were obtained to assess for occurrence as shown below in the pictures. The pathology, again, the slide shown below reveals self-serrated lesion with high-grade dysplasia this time. Okay, that's fine. Thanks very much. So, you know, a little bit of a surprise to us. We felt, if we go back to the slide you saw, we felt we had a good clean resection. We did near-focus, which we always do on the periphery of the margin, cleaned it out. So here now, if we give the audience the full endoscopic image of what we're dealing with now, so you can see, you can easily, it's a very flat lesion. Here the scar is very flat, and if it wasn't for the tattoo, I think it would be difficult to find, actually. You can see from a distance, you could roll right past that and kind of ignore it. But if we go up close, we'll be able to distinguish with near-focus and with MBI imaging, as you see here, we can clearly see, let's get onto our near-focus, yeah, we can clearly see the margin of the abnormal and the normal tissue. So we have a self-serrated pattern. I can't say at this image that we're seeing what I would call high-grade dysplasia based on the near-focus, but we'll come in a little bit closer here, and we can see as we roll around the top of the lesion, we're seeing a little bit of irregularity, JNET2B there, and we can see the margin here. And some of these abnormal crypts in front of us on near-focus. So, yes. Greg, this is Ale. Ciao, Greg. Hey, Ale. How are you, man? I'm good. How are you, man? I'm good. So, question, looking to the lesion, does it look like a recurrence of this? Can it be a new lesion that you didn't see in the past that it was? Honestly, no, it's a good point, but luckily, the referring doctor tattooed opposite the wall here, over here, get rid of the, anyway, there was a tattoo on the opposite wall to begin with, and so we knew that this was precisely the location of the original lesion. I mean, could have been a satellite beside it, I suppose, but I'm not going to... You know, the borders are very sharp, very clear. It doesn't look like a border or a recurrent lesion. So what I'm going to do now, it's very critical for us, it's going to be hard to find this when we come back with the full thickness device, because it limits your visibility. And you can see here, if we go up close, we see the... We mark it right at the edge. We do not mark it sort of in the ESD fashion, five to 10 millimeters away. Greg, can you comment full thickness versus ESD for this lesion? What can be the advantage of having full thickness rather than standard ESD? Well, in this case, it's sort of a recurrence, and I think there'll be a lot of fibrosis underneath here. And so I think to go back, for instance, with ESD would be challenging, and it's a small enough lesion, I think that we can get this into a full thickness cap. We'll see in a moment if we can do that. So I think it's more efficient, and we'll have certainly vertical RO margins guaranteed generally with full thickness resection. We published a series of ours on 65 in the colon. We did have 12 cancers in our group of 65, and of the 12 cancers, we had RO resection, even though there were two T2s and a T3, we had RO resection in 11 out of the 12. So pretty much equivalent to what you would expect with ESD. Just want to get that mark on the backside. We'll go off of near focus to get a better view. We're still on NBI, of course, to distinguish the margins, which we can see over here. So what we're going to do is we're going to change... Dr. Haber, we have a question from the audience. Yes. Is this the type of lesion where chromoendoscopy would help? What's that? What's the question? One more time, please. The question is, is this the type of lesion in which chromoendoscopy... Do you want us to come over here in like a minute? Yeah. I'm ready. To do chromo? Well, we have virtual chromo with NBI and near focus, so we don't generally do chromo on top of that. So we can see we have our marks here, and we can see the backside mark there. I may want to put one more up here on the top right. So the objective will be when we get the specimen, we hope to see all our marks to ensure that we have the entire lesion. Now, the one thing you do get with full thickness, the clip that you use to secure the back wall will of course necrose off much more than what you've just taken out. But the objective, of course, is to have RO on resection. Okay. So now we have our lesion marked. We're going to come out and change scopes. We're already set up. Now, you will see the big challenge coming up based on what it looks like as I come back. This lady has... We're up at around 80 or 90 on push-in. She has extensive diverticulosis, as you'll see, and it will be challenging to get through. The standard FTR device, FTRD device, has an external diameter of 21 millimeters on the cap. So it is big, and even the diagnostic or the upper is a 19.5 external diameter. So we may have to back to a smaller device. Hopefully we'll get through with the standard device, which is the plan. So we're coming out here. It's very important, if you're doing FTRD, try to clean out as much as you can, which we've done. Our prep wasn't perfect, but any of this stool that she has from the ticks that pops in, it's going to interfere with our visibility a little bit. So we'll just go ahead and change scopes here. Now the cap... Yes, go ahead. I'm sorry to interrupt, Dr. Haber. Nice demonstration. We'll transition to another room while you're changing the scopes, and we'll come back to you in a few minutes. Sure. So let's go ahead and change scopes. Yeah. Oh, we're live. Okay. So we've now... Could I get a little needle so I can go through this? As you can see on the endoscopic image, we have the full thickness device attached to the end of the scope. A little bit of poop in the way. She has extensive diverticular disease. There are two things we do. We've given her glucagon, which we give just before we go forward with the FTRD device. And then, of course, we try to wash out as much of the stool as we can. With this cap, it extends 23 millimeters beyond the tip of the scope. So you really... Just a second. Let's see if I can get rid of this. There we go. Just trying to get rid of that poop. So it's sort of a slightly different technique to go forward. There's a lot of pullback and a lot of sort of twisting and torque. We did have prepared in the background the PCF scope with a 19 and a half diameter FTR, which is one and a half millimeters smaller. Not a huge difference, but we may have to resort to that. The other thing we have available is a CRE balloon. So we can use that with a wire in front of it, use an 18 to 20 CRE balloon in front of us to try to get through these difficult areas. So we're about, I would say, halfway there maybe. So if you want to go and come back or you can stay here. The actual internal diameter of this large cap is about 13 millimeters. So in terms of the size of the lesion you can get, it's what you can pull into the cap because the depth of the cap is 23 millimeters. So if you're obviously dealing with a mucosally based lesion and not too much muscle, you can pull a lot of it in and it will go right in. Now, if you're dealing with a gist when we do the uppers, of course it's firm, it's nodular, then you couldn't really get anything more than about maximum one and a half centimeters. Whereas when we measure out what we get on the colonic ones or the mucosally based ones, we routinely get about a two and a half to three centimeter pinned out lesion at the end. Greg, do you use a split bowel prep because I'm concerned that the patient is not well prepared and that's the issue, split bowel prep? Yeah, a standard bowel prep. Yeah, because the patient is not well prepared for this kind of endoscopic surgery, bowel prep should be very different, much better. Yeah. I think one of the problems is her extensive diverticular disease that she still had a lot of fecal that's inside the tics. And when we go in with the preliminary evaluation for the marking, we do try to clean out as much as we can. So now we're at the lesion coming up on the right. You can see the importance of the marks in order to identify exactly what you're going to pull out. So, Dr. Haber, you nicely came there and I know you are very skilled. What do you think about people who have less skill if you use a device like Dilumin or something to advance through it because it might be much harder for them? I don't think, don't forget the OD of the cap is, as I said, it's 21 millimeters. I don't know that that would go through the Dilumin device. I'm not sure of the limitations of what will go through. I want to make a point here about the full thickness. Now, the snare, the heel of the snare is coming at six o'clock out of that channel and the snare, of course, is embedded in the tip of the cap. So when we actually suck the tissue in, you're going to get much more coming in from the 12 o'clock direction than from the six o'clock direction. So we do make a point of making sure that we have the near side in and with a little bit of suction, the far side will often pull in. So we'll take the grasping forcep. So we have a grasping forcep here. Now, the first thing I do is before I do anything, I'm going to review this with my fellow, Cayun. So do you have the Rube camera? Let's just, can we show this? I'm not sure. This is basically the snare. It's got a safety bit of plastic in it so you don't inadvertently deploy it and open it up while it's going in. And of course, you see here the typical ratchet device we have, the string that will, of course, pull the cap over the lesion. So we'll take that. And we have a cutting current. And so basically what we'll do is we're going to grab the lesion, suck it in, and then I'm going to turn the handle here to, with this string, and that white ring will push forward to push the cap over the lesion. Now, like all the vesicle devices, as that cap goes forward, it pushes the tissue away from you. So you have to be prepared for that. So don't, you don't want to be pushing against the tissue. You want to pull the tissue to you. Okay. And then after we do that, after we pull it in with a little bit of suction, then we will show you what we have. A little bit of, sorry, debris, and we can just clean that out. Okay. Okay. Now, you want to make sure you open up outside. If you open up inside, it gets stuck inside the cap. So I'm looking there and there. So this mark here is about the center of the lesion. Open. And so I'm going to go there, right in the middle, close. And now I'm going to draw it towards me. A little suction to take the air out of the colon, a little suction. All the marks are up here now. We've got most of it up in here now. Now, the next most important thing is to hold this up here, please. I'll hold this. I'm going to start, just a little tension on this as I pull up. A little suction, and the release requires, just keep a little pull up. Keep it tight. We're going to gradually, I'm twisting, twisting, whoop, it fell off. Hold on. I'm going to pull up anyway, and I'll, there we go. Cut. Got it? Okay. Okay. So it came up, I was able to suck it in, and now we're inside. Let me just push it away for a sec. What we usually do is come out and go back with a regular scope, but let me just push this away so you can see what we have, and then we'll grab our lesion. So there you see you have fatty tissue, probably substeroidal fat. The white on the outside is the muscle on the periphery, and our clip has engaged this whole thing. So now we'll get the lesion and we'll pull it out, we'll have a look at it, and we can show it to you on camera. Okay. So we'll just open up, we'll close, let's come out and quickly show you. There is a small risk of delayed bleeding from the center. This has happened to us in one out of a hundred, it's been reported, delayed bleeding. So we often go back, we look for any visible vessels or any evidence of bleeding. Okay push forward. Okay, open up. Okay, just take that. Now, Sean, can I have this camera come in close over here? Thanks. Before we leave, and I know you've got to go on to other cases, I do have to recognize a team here that's worked very hard to make sure you've gotten this transmission. That includes, of course, Sean over here and Kennedy and a bunch of others, Antonio and Julia and Thuy. So a lot of people involved as usual. So let's get a closeup of the lesion, and you know, it might even be easier with the scope. I think I'll do it with the scope. Just a sec. Yeah, I'll bring this over and we'll put the scope, we'll just use the scope to, you can look at the scope image. Just take that. And we can see it here, yeah. Take off that cap. Just take off. And we'll see both sides, and you can see what we've got. There we go. That's good. And I think that'll be enough to see. Oops. The string has to come off. Just a sec. Just undo the string there. There we go. I got it. That should do it. Okay, good. That's good enough. Yeah, that's good. Thanks. There's a little ruler. Okay. So now you see our marks we've got there. We obviously have excessive tissue on the top side, but the near side mark is that one down there and there. So you always get the six o'clock, you'll get that. But as we, you notice we had to suck because we lost it. We couldn't grip, it wouldn't pull in. And as we suck, what you usually get is a little bit of excessive tissue there. Now, if we look on the backside, let's see what we have. I haven't looked yet, but I think even Professor Saito would be happy with the vertical margin here. We have cirrhosis. So this guarantees, of course, vertical margins. And that's why on our series of 100 or so, the 12 cancers, even a T3, which had positive perineural, no lymphovascular had intact cirrhosis. And at surgery afterwards, 58 nodes, all were negative and nothing left over. So it's got a tremendous potential for lesions, especially when you're not sure of the depth that you want to ensure in RO margin. So we'll pin this out, we'll send this to the lab, and we're going to go back and have a look. So that's basically what we want to show you. Greg, Helmut speaking, may I have two short questions? One on complication. You mentioned bleeding is one complication. Did you ever experience a stenosis after resecting a lesion which was quite large and then the colon gets obstructed? That was my first question. Okay, I could answer that. Thanks, Helmut. It's a very good question. I have not actually had a stenosis. We just don't get that much tissue with a single grab. I mean, even two or three centimeters in the colon is not a lot. Now, I can tell you about one complication I had in the upper GI tract, a lesion in the duodenal cap, which was very close to the pyloric ring. And I had to have the cap on the gastric side, and as I pulled the lesion from the duodenum into the cap, it sucked in the opposite normal mucosa. At the end of the procedure, I had a completely closed off pyloric channel. Not completely, however, I could get a wire through. So in three or four days, the normal mucosa closed off, and then the pylorus opened up again. That was the only real obstruction I had as such. Okay, because I really had a complication with the stenosis of a patient who had a colon obstruction and got an ileus, but it results from the treatment and disappeared. My second question is, just in case, this would not be an arterial resection, how would you approach? Would you remove the clip after a couple of weeks and then perform biopsies or repeat the procedure? Sorry, the question, if this had not been successful, you mean? If a pathologist cannot confirm an arterial resection. Oh, I see. Yes, yes. So if there's no arterial resection, I mean, in this case, of course, we have cirrhosis, so I'm not worried, but I always check the specimen. If I don't, and if it's not arterial resection, we obviously go back, and we have to take more biopsies. Now, what your fallback position would be is, I think ESD would not be an alternative at that point in time with all the fibrosis, I think you have to remove it and go back and do another full thickness to pull in what you left behind. That's what we do as well. Okay, thank you. Yeah. Now, the only other complication, well, okay, we could talk forever, but thank you very much and a pleasure. Thank you. Great procedure.

colonoscopy

polyp

serrated adenoma

EMR

lesion

FTRD