Dr. Nix, we are back to you. Thank you. John's going to present the case. So case four is a 47-year-old male who had a screening colonoscopy, showed a 40-millimeter screening or lateral spreading tumor in the hepatic flexure, displaced ending colon, scraped over the fold, biopsy with a tubular adenoma tattoo was placed, but it was not told where it was in relation to the lesion. Two other small TAs were removed, and the plan today is hot EMR with lip closure or with X-stack or without clips. So, thanks, John. So, you know, it's interesting that the thing I like to get the most from referring doctors is actually photographs. It actually helps us triage because you can get a little bit of a sense from the morphology of the lesion the likelihood of cancer. And this lesion is the one that we moved up just a few days ago from the schedule because I didn't think it was going to have cancer in it because it looked granular, but I thought it was going to be a bit interesting because the photographs look like this, and then you could see the other side in retroflexion. The doctor had done a retroflexion. So, it's in the hepatic flexure. We're right above the ceca, and this is the most common area where we sort of need to get into retroflexion to access the lesion. But after looking at this, I'm not really sure that we do because you can sort of get at the proximal edge. One thing I think it's a mistake to do when you're in the hepatic flexure is to inject over here on the anal side of the lesion because you'll tend to push it over this fold down into the right colon. So, even if you don't think you're going to have to do a lot of reception in retroflexion to get the needle really close to the cecal edge of the polyp is good. And you can see we can sort of access that edge from here. And the other thing is in retroflexion, I'm not sure that this fold right here, the one that's underneath the catheter, won't be in our way. But just to give you a sense of this, I think it's an important tool to do. John, will you put a little bit of lube on the scope for me? I want to go down. I usually go all the way down into the cecal cap when we're going to do retroflexion. I have a cap on the end of the scope, which we usually have for EMR. And, you know, you have to be a little bit careful about using the cap when you go into retroflexion. But we'll get into retroflexion. That's a valve right there. And then sort of pull our way back. And I've already put the catheter down. It's usually better to put the catheter down before you go into retroflexion just in case it's difficult to get it out. But you can see the access to the lesion. Actually, I'm trying to push the catheter out right now, and it won't go. So I've got John trying to do it. It's right at the tip of the scope, and it doesn't want to come out. But you can see how we can get at... So what I'm going to do is actually repeat that. But I'm going to just stick it out just a hair to make sure that it's... I'll put it right at the edge of the cap. It should be okay there. And then I'm going to go back into retro again. Okay. So now we can visualize... Needle in, John. We can visualize the exact proximal edge of the polyp. And inject it. Go ahead and inject it. Typically, a granular lesion like this, these kind of bulky granular lesions, lift extremely well. And needle back. Before we started, I looked over the entire surface of the lesion. Needle in. Oops, sorry. Let me try it one more time. Okay, now try it, John. I looked over the entire surface of the lesion to make sure there was nothing that looked like it might have. It might be cancer or malignant. And so the other thing I would say about this, and I should have demonstrated it, but I think this would be a great lesion to remove underwater. You could probably take this out in a couple of big bites with a needle back. And so now we've injected it. I don't think resection is going to be that great, you know, in the retro view. But let's see how it looks. Hi, this is Mohammad here. I have a question regarding partial injection versus complete injection. Like what is the strategy? Should we inject all the back border of the lesion or just focus injecting small area, remove it, then inject again? Yeah, Mohammad. How are you doing? I'm good. Yeah, I would say oftentimes better to just inject part of it, get that part off, and then, you know, and then re-inject. So it's kind of inject and resect and then re-inject and resect. And I'm going to use a 20-millimeter snare. I often say that if you're in the right colon or just in general, kind of try to confine yourself to 15 to 20-millimeter snares to reduce the risk of complication. Because I think the bigger the snare you get, the more the tendency to grab the muscle. And let's see if I can get up here. And I was not even tempted this time to use a 25-millimeter snare. I will say just in general, you know, that you don't have to use the whole snare. And I'm kind of going about this a little bit funny, but I think it'll be okay. Close. And, you know, so we've got a good grip on it. We might talk a little bit about current because I always used to use Endocut for EMR, but I've entirely switched back to the way I started, which was force coagulation current. And I did that because of the U.S., again, largely U.S. multicenter trial. And this paper was in Gastro, which showed that using force coagulation current actually resulted in the same amount, open, John, of I'm kind of doing this backwards. I usually start at the side closest to me, but it's just not quite working out yet. I'm going to come over here and do this the right way. It's usually better to start on the side closest to you, which is, you know, usually the anal side of the lesion. Close. I think that'll be okay. So, anyway, we all very commonly used Endocut, you know, because the theory was that you got less thermal injury to the wall and close, and you were less likely to get an immediate hemorrhage. But, so look right over there. See, there's, I think there's just almost muscle exposed. See it right there? Just a very thin layer of submucosa, probably because I didn't get it injected quite as well as I should have. But, so that would be, under Michael Burke's scheme, a type one muscle injury where the muscle is exposed but not actually cut. And I'm referring to this little white place right there. A little bit of muscle. But, anyway, no big deal. So, is the patient under general anesthesia or under propofol for procedures? They are under propofol. Okay. Yeah, we did, I give, this is totally unproven, but I give a significant number of my patients a dose of Reglan before, let's inject a little bit, John, before we start because I tell you probably the most common problem that we have if we have a procedure that goes 45 minutes or an hour is at some point the patient refluxes and then everybody's really worried that they're going to aspirate, and occasionally they do aspirate. So, we like to pay a lot of attention to that. And, you know what, John? So, but we generally use propofol injections. Sorry, John, hang on a second. But I was saying that, so the randomized trial injections showed that it looks like that's in the submucosa. It's bowing out like it's in the submucosa. Needle back. I think that's okay. It's not as blue as I expect. Needle it. Try that again. But Heiko was the lead author on the trial, and it showed that, okay, that should be good, John. Let's go back to the 20 millimeter. That the risk of delayed hemorrhage was actually no different when you use forced coag current. I actually thought the trial showed that there were some advantages to forced coag, and specifically they were that there was less immediate hemorrhage. And then if you, then with endocut open, if you looked at the perforations, there were three immediate perforations in the trial, and all three of them were in the endocut arm. That's not as blue as I'm expecting over here, but why don't you close, John? This is Alessandro. Hi, Alessandro. How are you, bud? I'm good. So, question, just watching your procedure. The main problem I see is that you are very unstable with the scope. This is because the lesion is located at the hepatic flexion. So can you comment on this, just in this case, what you can do to make the scope more stable? I think maybe I should let you do that. I'm not totally sure where you're going with that, but I agree it's a little bit difficult. I think deflation, so we don't have as much tension on the lumen, is good here. And then, open. You know, possibly going into retroflexion could be helpful. Exactly, working in retroflexion should give you much more stability with the scope, no? Yeah, yeah. Closing. Because the lesion is much bigger than it appeared in the... It's much bigger. Yeah, it's about five to six centimeters overall, right? Yeah, but again, because of the, you can see how we're just really having no trouble with subnucosal fibrosis. Yeah, that's very nice. Yeah, you're right. And the lift is so nice. Yeah, it's persistent. With these kind of bulkier granular lesions, they often lift extremely well. And closing. Can you comment, based on location and size, and also appearance, is the risk of intramucosal cancer or more advanced histology very limited, despite the fact it's a big lesion? I mean, I would say the risk of cancer, subnucosally invasive cancer, is extremely low here. You know, I would think one or two percent. And opening again. Hey, Doug, before you have completely removed the lesion, I'm seeing how you nicely anchor the tip of the snare and then direct the direction of the snare so that you get most of the lesion from the beginning. So do you want to comment on that here? Yeah, no, I mean, I think it's important. You know, I'm using a kind of a big snare because it's, you know, it's... I don't know. You know, again, 15 to 20 millimeters is all appropriate. If I put the tip of the snare right out over the edge of the lesion, then I am having a hard time holding this position. So Alessandro's point is well taken. But if I put the tip out over the edge and I hold it there, then I can use as much of the snare really as I want, and as John is closing. So I'm just going to come back. I'm trying to come back without flipping out of here again, which... Let's see if I can get the rest of this in there, but... I may be pushing my luck. Let's close on that, John. I still have that tip out there at the same place. And so one more bit over here to go. But, yeah, I think that point's well taken. Anytime you're using a snare, if you place the tip where you want the tip to end up and then get over the tissue that you want and then... Closing, John. And then, you know, you advance the sheath then. So I think there's often a tendency as you're closing to, you know, like, say you've got a bunch of polyp open here, and so, you know, you will want to, you know, stick the snare way out past that polyp and, you know... Doesn't want to open, does it? But you can, you know, place the tip where, again, where you want it to end up, and then you're being a little... You're using a big snare like it's a little snare, really. Closing slowly, John. Hi, Doug. It's Helmut speaking. How are you? Good. How are you doing? Thank you. This is a very nice procedure and a very challenging... I lost... Sorry, I had some problems, but now I'm back again. Okay. Maybe you will ask it in the meantime, but I'm wondering is a snare tip coagulation of the borders not necessary? I mean, you resected very nicely, although regular mucosa. So I'm wondering whether this is now the new gold standard or should we just leave it if we have a safe resection of regular margins? Yeah, I think I understood all that. I typically will do the snare tip soft coagulation treatment because we've piecemealed it. So I really like to get these very, very low recurrence rates, you know, that have been described. I will tell you that we just submitted our data on snare tip soft coagulations 40 millimeters or larger. Yeah. And we had previously for lesions that size, I think someone was saying earlier that... Very slowly, John. Maybe a bit more than that. I'm sorry. Someone was saying earlier, you know, the average recurrence rate traditionally has been 15 to 20%, but it's very much size related. So above 40 millimeters, you know, you are... So I could eject that. I'll just eject it here and then we'll take it off. Above 40 millimeters, you know, our recurrence rate traditionally was 35%. Okay. So we have lowered that in the snare tip soft coag era. This is maybe 130 lesions or so. Right. That's 9%. Okay. It's not as low as ESD, but it's substantially lower. So I'm pretty consistent and I would plan to do it here also. Okay. I think people have raised questions like what really injecting... I'm really wondering if, as shown here, you have regular mucosa, very nice resected on the margin, whether it's necessary or do the recurrences occur because sometimes we leave some small areas in the middle of the resected area. Yeah, I hear you. It might be that case. On the other hand, you know, the data is the data and the data suggests that the recurrences come in from the margin. I think we, you know, when we have randomized trials, we should believe them open. Yeah. But I think that one of the things that is definitely true... Will you close on that, Sean? Okay. I think that'll be okay. A little bit of normal mucosa, that's fine to get a little bit more there in the snare. So now, you know, when we started doing snare tip soft coag, you know, I've heard people say maybe we really started looking a lot more at the margin, you know, to make sure that we had all the tissue. Yeah. Maybe that's the secret. Yeah. So I think that that's reasonable to speculate about, that that contributes to it. But, you know, we have a trial from the UK, going all the way back to 2002, the St. Mark's group, Brian Sanders, and all those guys. Could I get, John, the avulsion forceps? Okay, now this is maybe obsessive compulsive behavior, but I do think there's maybe a little bit of polyp tissue right there. Yeah, yeah. The base. And so I'm going to avulsion. Yeah. So, and, and again, now this vessel here, that's not an artery. The big one. The smaller one might be. But again, we can, so we can close this either with with X tack or with clips, I will say it's kind of perfectly oriented for clip closure. So I'm just going to slip over here. Dr. Rex, thank you for all this demonstration, we may come back to you based on the time, but we need to transition to another room. Gotcha. Thank you. We will go to Dr. Rex from Indiana. Hi everybody so we're just back here to show the closure. And I decided to use Boston clips, you can tell sort of tell there's two different lengths of clips on here. I started with the 17 millimeter the ultra clip, and I use that because the polyp was basically along a ridge, and the way that that clip opens it doesn't open as widely as actually the same angle of open as the, as the 11 millimeter clip, but it has very long arms, so it fits over a ridge. And the other place I like the ultra clip a lot is for closing lesions on the ileocecal valve. And then the other thing we did here was just one on the other side of the defect, and just bent these clips at the lower and I started to lower it, bent them back, and that allowed a specific expose the, the other end of the defect so so it's a good tight clip closure along the, the full length, and that's all I have to show you there. Great job. Can you comment on the cost of using so many clips, how it's impacting on the procedure and any other solution. Yeah, it's expensive. And so, you know, anyway, look at it, it's, it's expensive and I think, I think Heiko was mentioning that, that, you know, it's a factor that favors cold resection, because, you know, when, if you have a cold, if you have the opportunity to do a cold resection we really should probably talk some point about contraindications to cold resection I think anytime you're concerned that there's cancer. If you have a bulky lesion if you have a pseudo depression, you know, you really want to use electrocautery if there's any suspicion of cancer but when you take these things off cold. The thing that makes cold resection cost effective is you're not using the clips, you know, I will tell you in the US that we are complication averse, we don't like, we don't like patients to be in the hospital. And I actually think in small communities in the, in the US towns of 50,000 60,000 and smaller, that the single factor that drives so many patients, getting sent to surgery for benign colon polyps is fear of complications, because when you're in a town that size, and you have a complication, you know people are going to hear about it if you have it on on one of the prominent local citizens you know like that. The high school football coach, or the high school principal, you know, can know you had a complication they're not going to understand it, that you know you did everything right. And you still had a complication so so I think we're, we're kind of complication averse. And you know the ability to lower the hospitalization rate to, you know, I think is is worth it. So, it's a very important question and we need these clips to become cheaper and we need cost effective. You know, things that are more cost effective for for closure so it's a good point. Anything else. Okay. Just a brief question. Do you want to comment because I get the question a lot so what how do you define complete closure. Yeah. You know, I think I go and you can correct me that in our study. We said that if the space between the clips. If there was a space that was more than a centimeter, that that was not a complete closure or if there was a, you know, a gap or a portion of it that you couldn't close, I should ask you how to go what is that the definition that that we used your definition was which, which was less than one centimeter apart, and no or a minimal visible something calls on. Yeah, I mean this is pretty tight there. I would consider this a complete closure. Yeah, I was pretty much pouring this on. But, you know, I mean, there's some evidence this was true it in the Spanish study the out the Eduardo about being a study. If you go back to our original study back in, in 2013. There was a difference between complete closure partial closure and no closure. And, you know, partial closure in the, in the Spanish study was not was not so good. And in our study it was, it was very intermediate so I don't know I'd rather I'd rather just, you know, close the whole thing pretty tightly. Thank you to the team for the nice demonstration and the discussion.

screening colonoscopy

hepatic flexure

polyp removal

retroflexion

snare-tip soft coagulation

Boston clips