We will go to Dr. Rex from Indiana University for some case presentations next. Okay, this is a case 3, this is a 62-year-old female who underwent a screening colonoscopy in June. I found a 30-millimeter, what was called a cephalo lesion in the cecum. Biopsy was a tubular adenoma. On review of the photos, it was a granular LSD. There were three other lesions, 5 millimeters in the hepatic flexure removed with a cold snare. There were also two adenomas. The plan today was a hot EMR with a clip closure. So thanks, John. So hi again, everybody. We actually were not going to show this case. We originally were, and then it looked like perhaps it was going to be a bit too easy. And so we elected to move another case onto the schedule, but it was inconvenient for her to come on a different day. So I actually, I felt like we were going to try and squeeze her in before the second half. But I thought we would show the last part of that. The lesion was granular, very flat. It was bigger than expected, probably in the range of about 4 centimeters, and we're in the cecum on the lateral wall opposite the ileocecal valve. One thing I liked about it is the referring physician did not biopsy the lesion and did not tattoo it. We actually sometimes see tattoos, you know, being placed in the cecum and probably never need one in the cecum. And you can see that there's quite a bit of fat exposed in the base, which is not, you know, unexpected in the right colon. On the ileocecal valve, that's a virtually universal kind of finding. And we resected all of the lesion except a little bit, see an artery pulsating right there. There's a little bit of tissue that I missed that I'm going to avulse using hot avulsion. Right now, Ryan's giving me a little bit of pressure to get a little bit more gas in the colon. We're, of course, using CO2. We don't want to over inflate, but we're, you know, we're doing this process of thermal treatment of the margin. So I think the key here is, you know, you want to be aggressive enough to, you know, to try to destroy all the cells that are at the margin. And then we'll avulse that and then close it. Doug, a couple of questioners have remarked upon the limited motility in several of these cases. Are you using a glucagon or another agent to arrest the motility? No, I'm just being lucky. You know, it's an interesting point because if you're in a location, either where there's a lot of respiratory motion or the patient is losing a lot of gas, you know, it obviously makes the work much more difficult. So I mean, so yeah, it's nice. I agree, but I think we're getting lucky. Ryan is holding a little bit of pressure, can't see her. And I actually have a bit of a loop in the scope. So I'm pushing my way back in there. But the idea here is to get a pretty, you want to get a pretty thorough burning of that margin. You can see I did some of that off camera before you guys got on here. So yeah, but just lucky we're not giving glucagon. I tend to not use it. We don't really have hyaluronidine available most of the time in the US, you know, for IV use. Yeah. So this is a little area, I did have a couple, I'm not using epinephrine, maybe we should talk about that and see what people think or like to do. I tend to not put epinephrine in anymore, because I seem to notice clinically that patients were more uncomfortable if we pumped a lot of epi into the colon. So when we do use it, I usually dilute it to as much as 1 in 400,000 to 1 in 500,000. But oftentimes, they just don't use it. So it's a little bit bloodier here in the base than usual base doesn't look perfectly clean. But we find that most of the patients seem to be pain free much faster. So we're going to remove this last little bit here with hot evulsion. So we've got hot forceps, only time I use hot forceps in colonoscopy, Ryan's going to open just enough to get over the edge. Then we're going to try and place this so that close right. So we've got just a little bit of overlap into the adjacent submucosa. And then we're going to tent a little bit. And we're going to apply just tapping the yellow petal with endocut eye. And I'm going to take that. So I find this to be very safe. The alternative, I would say that one thing we don't want to do is to, you know, treat these little areas with APC or something like that, because that's been associated with a higher risk of recurrence. So everything that looks like it's viable polyp in the base, we want to actually resect. And if we can't do it with a snare, we either miss it or if it resists snaring, because it's extremely flat or extremely fibrotic, then open just a bit, Ryan. So you see, we can control the size of close, size of the forceps, just a little bit of tenting to get away from the muscle and just a tap on the, on that cutting current. And so I feel like this would be okay to close now. And I've attempted to, you know, do X-tack here also. I'm not sure that I would get this closed with one X-tack. I kind of think if we started up here, went down there, I wouldn't be willing to go all the way to the other end. No, I think we're just going to close it. So I would probably end up, if I did put an X-tack on, I think I would probably have several clips on one end or the other, or else put a second X-tack on. As Moen was saying, there's only four tacks in the set at the present time. Hey, Doug, could I ask you a question? So there's a little island of potential polyp tissue left, like at the low, at the bottom there, at like six o'clock, five o'clock position. Yeah, thanks Heiko. I think it's loose. Okay. But I could be wrong. And I also think it's normal. And that's why I burned it before. And now you can't see the pit pattern. But you know, Heiko, I want you to be happy. So let's... You know, it's tough to really understand what is polyp tissue and what's not sometimes. Yeah, when I was doing STSC, I thought the pit structure was normal. So but you know, if actually, if I thought it was really important, but I think it is normal Heiko. But it does look like a little island there for some reason. But I think it's normal tissue. But thank you, Open. So okay, so we're going to go, we're going to try to sort of zipper this. And it's okay, you know, to put clips into the base, into the submucosa. I'm turning the first position, Ryan. So when we say first position, we mean to close the clip, but not fire it, and then fire the clip. And it's very important to try to manipulate the tissue, so that the clips are buried into the tissue. I think it's much better, the clips are more durable, Open, if they are all the way. And hey, John, I'm a little bit concerned, I may, I might need pressure again. So I'm going to go over the, yeah, I'm going to go over this clip, and bend in here again. Actually, I'm okay right now, John, thank you very much. So I'm turning in again. Again, I got one prong over on the right in the submucosa, but I don't really care. First position, fire. And the clips are buried up to the hilt. This is the Cook Instant Clip, and it's a big clip, and it's strong. The arms are strong. You can push the clip into the tissue pretty well, with very little tendency for the jaws to bend, which I think is nice. So, and in a big defect like this, you know, that's an advantage to have a little bit more wingspan on the clip. So again, same thing. If I could drag normal to normal, you know, that'd be nice, but again, I'm bending down hard and right to turn the defect into me, and now first position, and fire. And then we'll keep this process going until we get to the other side. This certainly meets all of our criteria for wanting to clip. It's probably a 40 millimeter lesion. It's located in the cecum, so it's proximal to the splenic flexure, and used electrocautery to remove it. So I'll be doing this for a few minutes. I mean, if you guys need to break away, go ahead, open. And I'm not afraid to spend a little bit of money on clips. I think in general, first position and fire, now we got a little bit side to side. If I saw that artery, again, I should have been focused on that. A lot of times if I see an artery in the base, I will try to put the clip, you know, right across the exposed artery. Most of the vessels that we see in the EMR defect are not arteries. They're just big veins, and we've got a couple of randomized control trials that show that, you know, it doesn't really do any good to go around and cauterize those vessels. I know it's very commonly done by many experts to, again, see I'm turning down, and the defect is turning toward me. First position, Ryan, and fire. Thanks for not popping that back out there, Ryan, nice job. I wish I could introduce you to my team here. I've got two of the best techs around, Ryan and John, are with me today, and Ryan is rotating the clips for me. These clips are not really made to be rotated, but she just instinctively knows that she needs to rotate to get perpendicular to the defect. Let's go up just a hair more, Ryan. Okay, sounds good. Dr. Rex, this is a great demonstration. We'll transition to another room, and we'll come back to you after. Okay, sounds good. Are you guys back? Yes, Dr. Rex, you're live. Okay. So this is the closure on the defect, and I think there's one, two, three, four, five, six, seven, eight, there's 10 clips on there, and I might put one on that little thing on the end, but it's pretty tightly closed, and that's it. We're going to pick up the polyp and get out of here. Any comments or questions about that? Doug, I'm surprised that you clip into the mucosa. You approximate the margins by going to the submucosa, and then at the end, you might just finish this off with another clip there. I think I've done this on rare occasions, but that's still something I'm not usually doing. Yeah. I think the other thing about open ... Thank you for the point, Heiko, because I think it's a good question. I think there's no risk whatsoever in putting these clips into the submucosa. I've never had a problem with it for supposition and fire. I think the tip of the clip, because it is not sharp, I think some of the older clips where there was a sharp, pointy tip, you could push that through the submucosa, but I don't think it'll happen with these blunt, rectangular-shaped clips. If you have a defect that is maybe three to four centimeters across, and you can't spin it with the clip, if you put a couple of clips right in the middle of the defect, maybe two or three, and bring the edges together, now you can close around those clips, and at the end, you'll look like you have a full closure, even though initially, it didn't look like it was feasible. Now, obviously, at some point, you're going to get a defect that it's just too big to clip close, but ... I, myself, am a little opposed to picking up the mucosa on one side of the defect and dragging it toward the middle. I think that puts tension on the mucosa, and the clip is a bit more likely to disengage early. Heiko, if you look at our study, the one that you were first author on, one of the differences between the bleeds ... We had fewer bleeds, but you'll recall that the bleeds in the clipped arm, they actually occurred later in time. The non-clipped lesions bleed in the first day or two. The ones that are clipped tend to bleed a week or so out, and I think that's probably because the clips become disengaged, and that's when the bleeding occurs. Of course, the whole reason why they don't work in the left colon, maybe because of the narrower lumen and more solid stool, they just have more of a tendency to disengage early. I think we need to know a lot more about that, but having the clips stay on for a longer period of time, I think, is a significant advantage. That's great. Thank you, Dr. Rex and team. We will be concluding that here, and we will go to Dr. Saito.

colonoscopy

tubular adenoma

lesion

endoscopic mucosal resection

clip closure