Dr. Rex, we are back to you. We will start with your case presentation. John will present the case. Okay. Case two is a 52-year-old female undergoing, who underwent her first colonoscopy in June. Indication was positive cologuard and a family history of colon polyps. They found a 35-millimeter polyp in the ascending colon, which was biopsied and tattooed, came back as an SSL. In the cecum, a one-centimeter polyp was hot-snared in two clips that was also an SSL. A transverse colon polyp for a centimeter was hot-snared in one clip, also an SSL. Descending colon polyp, one and a half centimeters, two of those hot-snaring clips, they're both SSLs, and a sigmoid 8-millimeter cold-snare, which was a hyperplastic polyp. The plan today is to remove a large SSL by cold EMR if possible and clear the rest of her colon. So, thanks, John. So, hi, everybody, again. So, here's one of the clips on the cecal lesion. So, I just want to say a couple things about the management of this patient by the referring physician. So, the first one is, if you add up the number of SSLs that John described, the patient meets the criteria for seriated polyposis syndrome type 1. And I think that that's an important thing to recognize because these patients have an increased risk of cancer. And as soon as you recognize SPS, you automatically kick the patient into a shorter surveillance interval. And I think that's a really important part of recognizing it. So, the referring doctor took out, you know, enough lesions but never really called it SPS. I told the patient she had that before we started. The second one is that the lesion was biopsied. I'm not sure if it was biopsied here in the middle. There's a couple of divots in it. And I just want to say that that is something that you should never, I will go as far as say, never ever do it to a sessile seriated lesion. It has no value whatsoever unless you see a pit pattern that you think shows cancer. And in this case, because this lesion is so flat, there's a good chance that it will have tacked the lesion down. The places that I see where fibrosis occurs that results in tacking down are either a very flat lesion anywhere in it, or sometimes people will biopsy the edge. I think it's a mistake to biopsy the edge because it will tack that down. If you're going to biopsy any lesion that you're going to refer, it ought to be from a bulky part of the lesion. The third one is the tattoo. Now, I understand the rationale for tattooing, but a couple of things about the tattoo. One is you can see that it's underneath the lesion. I don't think that that is a big deal for EMR. I think it's a bigger deal for ESD in terms of submucosal fibrosis induced by the tattoo. In this case, I think probably if we run into submucosal fibrosis, it's going to be from the biopsies. The other thing is, I would just say in general, I see a lot, and this was the case here, people put in a tattoo and they don't specify where the tattoo is in relationship to the lesion. So every time you put a tattoo, you should say, I tattooed three, four centimeters distal to the lesion. I tattooed on the opposite wall, and try to stay far enough away. You've got to remember that these tattoos, they spread out really, really substantially over several centimeters. And with the new Spot EX, that's what I used in the last case to tattoo the rectal sigmoid junction. You don't need very much, especially for endoscopic follow-up. A half an ml to three quarters of an ml is plenty. So thoughts about that. We're talking about one of the themes here in the first half of the course is to talk about cold resection. And so the referring doctor removed everything hot, and it was all serrated. So I don't really know that, I mean, it would have been safer and faster again to do it all cold. So I would say that the entire spectrum of serrated disease can now be removed without electrocautery. Some people feel that if there's an obvious dysplastic, that you should electrocautery. I personally don't think there's any data for that. If I see a dysplastic focus in an SSL, I still just take it out with cold resection. I think maybe the biggest thing we don't know yet is if we even need to inject these lesions, because we have seen data of people removing them piecemeal with very low recurrence rates. So let's go, I am going to inject this, and I think it may be a little bit of value if we do run into some fibrosis in the middle there where those where those divots are. So we'll put the needle in. I'm using a 25-gauge needle, and we're using Everlift, which is a cellulose-based product, and try just a little bit of that, John. And it looks like that's going into the subnucosa. So John's going to go ahead and fill that up. But again, I just simply don't know if we really... You can stop there, John. So we will move over now toward those little divots, those kind of weird little divots in there. Needle in. And so as we continue the injection, we're just going to utilize our mound. We've got this nice big mound of fluid. So rather than start over, and especially right here where we're completely on FOS to the mucosa, we'll just extend by going in... Inject again, John. We'll just extend and push the mound up toward the other end of the of the polyp. And as it as it goes, we'll pull it, go ahead and pull the needle out, and we'll go there again. I'm sorry, John. Let's get checked one more time. So you could see how nicely when you do needle in, inject, how nicely it delineates the border of the lesion. Inject, John. But whether or not we really need to do this, I think it's an unsettled issue. And I'm a little bit biased that we probably don't even need to inject this. So I think the panel, it might be interesting to discuss whether people have converted to cold resection for SSLs for the entire group of SSLs. Go ahead. Stop, John. Or if you still feel that there's a segment of this group based on size, needle in, or the inject prevalence of dysplasia that you need to use electrocautery. But I basically, no matter, regardless of the size, needle back. This is not a very big lesion. You know, let's go ahead and get the cap cold. So I do think there's a little bit of an issue with this thing not lifting very well in the middle. And you know, that's probably from the biopsy. So those little divots that were taken. Could somebody look up the date that the referring doctor did the colonoscopy for me? I'll try to see how old that, those little divots are. Any comments about, you know, cold resection? Would everybody do this cold? Yeah, Doug, Brett here. I think a lot of us are moving to cold from your training of the last couple of years. And I'm not sure that's penetrated broadly, but it certainly is fast and easier. We're generally seeing lesions a little bit smaller than this one and cold works so well. Yeah. Yeah. Thanks, Brett. I would. So the key thing is, is a margin. So we're starting off with maybe, you know, five, six millimeters closed cut junk. And we got to dig in, get that initial bite. And, and then we can use the water jet to expand the space a little bit open. And again, margin over the submucosal defect on the right and a margin at the edge of the, of the lesion. Closed cut. And I usually will sort of suck up the pieces as we're going open, unless there's a million of them and it's, you know, they're all falling in the same direction. We can just pick them up later. So you can see right here is a little bit of, of serrated gland on the, right along the edge of the polyp, closed cut. And we basically have no limits on how big that we want to make that, that margin open. And obviously the other factor that's really nice about, about cold resections, I will say that the recurrence rate after a cold resection of SSLs across the literature has been, you know, really low. The highest one I saw was really from our center. Now that may be because we don't bring these patients back generally in six months, closed cut. I bring back really big adenomas in, in six months if we did a piecemeal EMR. But these lesions, I think they grow back very slowly. And I prefer, I think they're low risk lesions. A lot of people think, closed cut, that, that serrated lesions are high risk lesions, you know, for cancer. And if you actually look at the prevalence of cancer in serrated lesions, according to their size, it's about one seventh that of adenomas, closed cut. John, do you feel any, any a little bit of fibrosis there? John said he thought he could feel a little bit of, of hanging up right there as we get to the middle of this open. And I will occasionally close, I will have fib, you know, fibrosis will be something that will, you know, get me to convert to electrocautery for a serrated lesion. Now, so I was saying that we, you know, we don't clip these because we're removing them cold. But I don't know if you saw, closed cut, the retrospective analysis of a Heichel-Pohl's study that was recently published in CGH, which showed that clipping did not benefit, it didn't reduce the risk open of delayed hemorrhage, closed cut, when serrated lesions were removed hot. All the benefit was for adenomas. And so maybe even if you remove it with electrocautery closed, right now the evidence is you don't need to clip it if it was serrated. Obviously, you know, our rules for closure right now open are if we have a lesion that is, that we've removed with electrocautery and close and cut, John. Yeah, it's a little tougher, isn't it? Yeah, but it's going through okay. I'm not, I'm trying to not get overly greedy. I was saying our rules for closure are that if the lesion is open, 20 millimeters or larger, proximal to the splenic flexure, close and cut, and we removed it with electrocautery, we should close it. And usually by clips, although I think during the conference today, you're going to see a variety of closed and cut methods of closure. But obviously, we don't have to do that if we are resecting cold. So at some point, I'm sure we'll talk about closed, whether there's a set of adenomas that can be removed without electrocautery, but we'll actually save time doing this cold because we don't have to clip, close and cut. We don't burn up the edges. Some people, you know, I'm sure somebody's going to do a study of electrocautery to the margin of large, you know, lesions that are removed cold and see if that helps reduce the recurrence rate close. But there's good reason to think it won't be as effective. And now we're, I'm going to pull, I just pulled that through a little bit. That should maybe give us a bit of a submucosal cord. That's the first time I've had to pull the snare through the lesion. And I, again, I think it's probably because there's a little bit of fibrosis in the middle, close and cut. And you notice I'm not trying to get incredibly greedy here, open with the size of pieces that I'm removing, cut, because that kind of helps to prevent the snare from stalling. It, if the snare stalls and you, and you pull it through, you know, that's okay, open, but you know, it's not quite as, it's not quite as smooth, close. The evidence is that these little cords of submucosal tissue, when you pull through like that one, I didn't pull that through, but it's still got a little bit of a submucosal cord, that those are very unlikely, open, to have residual polyp on them. Close and cut. Doug, there's questions on the sidebar here about the size of the snare you're using and stiff versus soft, or even which snare it is. Close. So cut. This is the, is the Boston 10 millimeter Captivator. So it's a dedicated cold snare. These dedicated snares are still braided snares. You can see the braid on it. It's got a pretty good shape to it and open. It'll, almost always, if you don't push on it too hard, it'll, I'm just going to put a little water in there to sort of clear up where we are. If you don't push on it too hard, it'll typically last for the entire case. Closing, John. So, you know, the original dedicated cold snare was X-Acto, and for cold EMR, I would definitely use a thinner wire snare, one that has this thinner braid, because you're going to get more, close, you're going to get more drag on the snare if you are using a normal braided snare. You'll have to pull through more often. It's just not as, as clean and easy. Closing, cut, John. So, but, you know, in terms of small polyps, we saw the recent randomized control trial from Australia that, you know, indicated that it really, the most important thing, open, in terms of a complete reception when you're removing a small polyp, is to place the snare accurately. Closing, cut. And so that you get a nice rim of normal tissue around the polyp. So, here's our defect, and we should go around the margin, make sure that we don't see anything that looks like residual serrated glands. If there's any question at all, we can just, you know, cut it off. As I said, we're doing it cold, so we have really no, no, no sort of limit on how much we can, we can resect. And then, and that's pretty much it. Very easy. Procedure's over. So, cold EMR or cold resection, I wish I had another serrated. A lot of these patients with SPS, you know, when they come, they'll have multiple big serrated lesions. For the, in our referral practice, 30% of the time when the referred lesion is an SSL, we diagnose SPS based on the number of additional procedures, additional polyps, lesions that we see during the procedure. And so, just as we were in the last case, the first case, we were debulking the rectum of an FAP patient with cold resection. When you have a patient with SPS, and you have a large number of EMRs that you need to do, this is a very efficient way to get a large number of lesions out. And the other thing I think that's great about it is these patients have to come back for follow-up. And once they have a complication, they seem a little bit more leery, and you can just basically eliminate the risk of complication. Hey, Doug, a couple of quick questions here. Doug, can you hear me? Prateek here? Yeah. So, you know, again, a couple of similar theme questions are, you know, recurrence rates after cold snaring of SSLs, and would, you know, having APC or soft coagulation of the tips help, of the margins? Yeah, right. I think that's a question that's on everybody's mind. So, we don't have a trial looking at using snare tip soft coag or APC to the margin of cold resections. You could theoretically predict, or at least my prediction would be, that it would not work as well as it does with adenomas removed with electrocautery. Because when we use electrocautery, we cut deeper than we do with cold snaring. So, probably what drives recurrences with cold snaring is a resection that doesn't always get down through the muscularis mucosa into the submucosa. But nobody's done that study yet, and I personally don't do that. As I said, I think the risk, you know, cancer developing from a large SSL is actually quite low for reasons that I said. I typically, if there are any glands that have survived here, I would come back in a year to look at this rather than six months to give them a chance to be endoscopically visible so that you can target your treatment. And that's not guideline-based really. Even among the adenomas now, up to 30 millimeters, rather than bringing people back in six months, if we've removed them with electrocautery and we've done STSC to the edge, I'll bring them back in a year if they're below 30 millimeters in size because the recurrence rate is so low. Even with STSC. Right. Hey, Doug, some of the audience members are getting a little bit concerned about, you know, the clot and some oozing and stuff like that. Do you ever clip this at all? No, the only way I would clip this is if I saw, you know, steady, rapid streaming, very rarely you'll get an arterial bleed. And, you know, I usually... So this ooze right now, you're okay with it? You're going to go home and you'll be fine? Yeah, absolutely. Okay. I think Helmut has a comment to make. And just for the audience, if you could put your questions in the Q&A box rather than in the chat box, I think that would be much helpful. Helmut? Sorry for writing in the chat. I just want to make a comment on underwater EMR because we recently published our experience with this technology. And I think underwater EMR is for lesions which are not fibrotic. This may not be the case in this situation we're still doing. But if this is a... And the right chemical, a good technique which has a low risk for recurrence and in the experience and I think an attractive alternative to reduce recurrence rate and have long-term treatment. Yeah. Good point, Helmut. I mean, of course, depending on where the lesion would be located, I think you're right. Underwater EMR may be a good technique. Doug, one comment about anticoagulation. If this patient's on dual anti-platelet or on anticoagulation, when would you resume anticoagulation after cold EMR, assuming that you had stopped it? It's a good question. Before we do that, I just, as predicted, here's another one. Good size SSL, maybe five or six centimeters back. And I know you guys are ready to break away, but I just want to show you the other technique where we don't even inject. Because you can actually see the margin quite well, close. And I'm using the same approach and no injection. No injection. And actually, this has been shown now. Michael Burke showed it first, but it was shown in another large study in the past year. Recurrence rate is very comparable to when we inject. It may be sort of difficult for you to see the margin. And once you get that initial cut in, so we can use the water jet and just fill it up. And I think that this has a lot to say for it. Dr. Rex, that's a great demonstration. So we have to switch to Dr. Kashab at Johns Hopkins, who's accompanied by Dr. Repicci and Dr. Ortman. And thanks again, Dr. Rex. Thank you.

colonoscopy

cologuard test

colon polyps

sessile serrated lesion

seriated polyposis syndrome type 1

cold EMR