So, let's discuss a few tricks of the trade for polyp resection, some of the tools that can be used to overcome problems based on how patients and what they're referred for. I think these are some of the challenges that people often encounter. Size, flat shape, access to the lesion, a fibrotic lesion, sometimes from previous attempts at resection, and then a patient just has a whole lot of lesions. So, size in general can be overcome. Most of these lesions that are very large are granular lateral spreading lesions. They actually have a low risk of cancer, and they're usually not very fibrotic, but occasionally you'll find one that has either a very flat component or a fibrotic component. In this case, the part that's going up on the ileocecal valve here has a lot of fibrosis. You can see that fibrosis, the white material. And so, a technique that I like to use to overcome this is the CAP technique, and this utilizes this Olympus distal attachment, or you can use the Steris device that looks basically the same. And you'll notice that it's sticking out over the end of the scope, just three or four millimeters. And the technique is to place a small snare, usually 10 or 11 millimeters, at the most 15 millimeters, and put it over the tissue, approach the tissue very closely, and then suck that tissue up through the snare into the CAP. You can see the fibrosis there that we have captured. And this is a very safe way to get a hold of an area that's pretty good size that is resisting snaring, either because it's extremely flat or because it's got some fibrosis underneath it. So again, lay the snare up, approach the tissue closely, suck, and at this point, the procedure is blind. You see, we can't see anything. And so, the tech has to close and tell you when they feel the tissue, and that requires a little skill and experience. It's easier when they're first starting, if they use a flexible snare like the Boston CaptiFlex, the 11 millimeter CaptiFlex. Once they feel it, then you let go of the suction, take a look at the tissue, and then you can cut through it. And I've used this in terms of individual pieces, I'm sure thousands of times. I've only had a couple of muscle injuries associated with it. If you use a deeper cap, or if you use like a cap for band ligation or for EMR, like we use in the esophagus, if you use that in the colon, you suck the tissue all the way up into the cap, you will get a much higher rate of muscle injury and even perforation. So you have to know what organs, it's kind of safe to do this and how much to suck. For example, in the duodenum, you have to be very careful about using a cap technique, but here in the colon, generally very safe. That's the blind part of the procedure. Again, the tech tells you that they feel it, and then you let go of the suction, take a look at it, you can see again that fibrosis that we've captured in the snare down at the lower left, what's within the snare. So this is a great way to overcome very fibrotic tissue. Here is a non-granular lesion of the flat elevated type. So non-granular lesions, sometimes after you inject them, they're extremely thin and very thin flat tissue, even if it's not fibrotic, may also resist snaring. So once again, we are using this cap technique, and again, I just want to emphasize from a safety standpoint, don't put the cap out real far. You can see it sticking out there about three, four millimeters. So we put it over the tissue, suck the tissue up through the snare into the cap, and then close blindly. When the feel occurs, then let go and remove it. So the cap technique. Now the other technique that we use to deal with very fibrotic disease is avulsion, which is a forceps technique. And this is a lesion that's been previously partially resected along the distal edge. Almost a quarter of our referrals at IU, there has been a previous attempt, which led to resection of part of a lesion. So the distal edge of this was very fibrotic, and you can see that we've performed injection and standard EMR on the sacral aspect. And now there's this flat fibrotic part along the distal or anal side, and we're going to use avulsion. So there's two ways to do avulsion. One is with cold forceps. You grab it with cold forceps and pull it off, and then take the snare tip on soft coag and burn the area up. So that's cold avulsion, snare tip, C-A-S-T, the cast technique. But I like hot avulsion. This is the avulsion version from Greg Haber. So you grab it with hot forceps. Only time we use hot forceps in all of colonoscopy is for hot avulsion during EMR. Grab a hold of it with the hot forceps, pull on it so you get some mechanical tension on it, and then you apply cutting current, low voltage cutting current. So rather than using endocut Q, like is sometimes used for snaring, you switch over to endocut I, and we have this on the 141 setting. So there we've grabbed it, we've got the mechanical tension, and we just tap, tap, tap on the yellow pedal. And you can see that the tissue is separated in the same plane that we were snare resecting in. So obviously you can get smaller pieces of tissue. This isn't as efficient as the cap technique, but I will say that it is, when you have tissue that's really tough to get a hold of, avulsion will work when the cap technique won't work. Sometimes cap technique won't work. This is a lesion in the rectum that actually the referring doctor worked on four separate times before they referred it, which we'd prefer not to see. We'd rather not see any work on these lesions before they are referred. But I think if you can't get a lesion out in the first resection, if it's just technically challenging, probably better to refer at that point. But we were forced to use avulsion over a pretty significant surface area. So all those little areas that are red there, that's residual polyp. So we get the forceps out, a little bit of suction, sometimes closing the forceps slowly so that they sort of sink in to the tissue. Then once you've gotten a hold of the tissue, then get that mechanical tension on the tissue and then apply that low voltage cutting current, endocurrent I141 setting. So usually, actually, when there's been previous EMR, we just use standard techniques. We're more likely to have to use the cap or avulsion. This patient actually, when they returned, did not have residual polyp. Third tool that I think is oftentimes helpful for access is water filling. So we all know about water filling as a way of getting a higher rate of on block resection because when you inject, you make lesions bigger. If you don't inject, which we don't for water filling, then you don't expand them. And so you can get a lesion out that's 25, occasionally even 30 millimeters in size underwater. In this case, this is a pedunculated lesion. And when we resect pedunculated lesions, of course, they're most often in the sigmoid and the sigmoid is narrow. It's often angulated. Sometimes they're not lying in the way that makes it easiest to get around the stalk. What we want to do is get that snare around the head of the polyp. And then we want to pull back on the snare, pull it toward the scope so that the side of the snare on the secal side of the polyp, so we actually see it touch the stalk and preferably low on the stalk. It's best to treat all of these big pedunculated lesions like they're potentially malignant. And so I never put loops or clips on. I never do that. I always just snare them first because I want to get as far away from the head as possible. And if you put a loop on there, you're going to be forced up closer to the head. So you can see the water filling kind of raised the polyp up straighter and then the snare slipped over and were able to close low on the stalk. This is another example of this. This is a lesion that's on the proximal lip of the ileocecal valve. And this patient, this polyp is only about 12, 13 millimeters, but the patient was actually referred to a surgeon and then figured out themselves that perhaps another attempt at endoscopic resection is warranted. So when we go underwater here, everything relaxes and the ileocecal valve, what it does, it tends to turn at you and it's actually turning this lesion toward us so that it's more accessible. So it turned out it really was not a big deal to snare this. We're snaring this now with a 15 millimeter snare. And so it's one of the approaches. Retroflexion is another one where you can use underwater to improve access. Another trick that's important for access, especially in the ileocecal valve, is the cap. This is the cap that we talked about using it for resection, but now we're using it for access. And what you can do with this cap, as you can see, is you can bend the distal lip, the anal side lip of the ileocecal valve down. And now we're doing an injection into the ileum, actually on the distal edge and pushing the polyp out away from the valve orifice. And then we'll start resecting. You want to get the part that is closest to the valve orifice first, in this instance. But the key thing here is that this cap, which is allowing us improved access. And then finally, I just want to talk about numbers of lesions. I say this because I get referred fair numbers of patients like this. This is a patient who is about 70, been a smoker, never got scoped. And then when they did get scoped, they just have, you know, 40, 50 polyps in their colon. And none of them is individually very challenging to remove, but it looks pretty daunting when you just see tons of polyps and maybe 15 or 20 that are over a centimeter in size. So I view this as a situation that requires debulking. You can see situations that call for debulking in FAP patients, definitely in seriated polyposis patients. This patient does not have a polyp syndrome, technically. Genetic testing might be warranted, but we're using a combination of just cold sneering and cold EMR, and we're going to be able to debulk this colon and then maybe have the patient back in six months or a year, whatever you think is appropriate. And in a fairly short period of time, we can take out 30, 40, 50 polyps, including some that are reasonably large with an extremely low risk of complications. So these are some tools that I recommend to you to deal with common indications for referral. And I hope all of you are enjoying the ASGE live endoscopy course, and thanks for attending.

polyp resection

endoscopy techniques

CAP technique

avulsion

water filling