to Dr. Nam and Dr. Saito and team from Johns Hopkins. Antonia will present the case first. Antonia, go ahead, please. Thank you, Dr. Jha. Next case we'll be looking at is a post-socialized section. Operators in the room will be Dr. Nalman Phuong, joined by Dr. Saito and Dr. Kudosia. Patient is a 58-year-old female with a history of mental health disability in 2021, where a regional swimmer with heart EMR and PTM resection of a large rectal polyp at the outside hospital. Pathology at that time showed tubulobulous adenoma. In 2022, she had a repeat surveillance endoscopy, at which time we saw this 30-millimeter rectal polyp with a central scar about 5 centimeters from the anal verge. No biopsies were performed during this procedure. After reviewing the history and endoscopic evaluation, the plan is now to proceed with flexible sigmoidoscopy with endoscopic submucosal dissection of the large rectal polyp. Dr. Nalman, your line. Thank you. Hi, everyone. I'm here with Dr. Phinnison and Dr. Saito. You can see on the screen here, we have, this is a recurrent polyp after EMR was done last year, and prior pathology show tubulobulous adenoma. I estimate probably about two centimeters at the most. I can see scar here and scar here. So this is a flat lesion, 2A. And we examine with the white line and MBI. You can see nice type two. And we think this is the area that some irregularity here look like genetic 2B in that area. So the possibility of high cladisclosure or internal recursal cancer, but I don't see any area that look like deep invasive cancer. So the difficulty of this lesion is severe scar, which we expect to see severe submucosal fibrosis. We change patient position. Now patient's on her back to move water away from the lesion. I'm in a retroflex position and you can see a dented line over there. Dr. Saito, Dr. Peterson, do you have any comment? Yes, this is a different lesion. So I think it's a good candidate for ESB. Conventionally, you know, we have to treat in plastic. So it's a really good installation for ESB. We're going to start injection. We plan to use endocloth. Fully supply system to do submucosal injections. But before using that, I'm going to use heterostats mixed with methylene blue to make sure that we're in a submucosa before we use that solution. I try to avoid injecting into the blood vessel. Okay, inject. So now we're in. Okay, stop. Change to endocloth. So this endocloth, can you, it's in the spiral syringe because it's thicker than regular injection. So when you inject, we turn the handle for injection. We use a regular 26 gauge needle master and we mix methylene blue. You can adjust the amount of methylene blue however you want to. Go ahead and inject this. The nice thing of this is the lifting, vertical lifting is really nice. And that's hopefully stop, allow easier entrance into submucosa. Inject. So I would like to highlight here that Swanee is really utilizing the previous injection to continue injecting. It's almost so that instead of creating a new submucosal plane, she's already using the curated plane, which is beautiful technique. You can see here. Yeah, thank you for the comment. Yes, because I don't want to inject this solution into the muscle. It's already difficult. So if I did that, it will make it even more difficult. Stop me the back. So my plan is to perform dissection at the auto side first. And then from the forward view, perform dissection from the anal sides. Needle out. I can see that the top part of the vision didn't lift. Inject. So what it looks like is not elevating in the central part of the lesion. Probably you should start the section far away from the normal mucosa in order to have a big flap into the fibrotic part. Otherwise it will be very hard. Yes. Is that your plan? Yeah. So we have to at least a centimeter or a one and a half centimeter below the scar area. Otherwise it will not be able to get into the plane. Needle out. And the other option would be considering for this lesion to use the FTRD device. Let's stop one second. Needle back. Yes, I think that's another option. Because it's very easy. It's into the rectum, very easy to go through. Yeah, I think that's another good option. The problem that I have is sometimes I cannot get on block with the FTRD injection, please. Particularly is scar area. Stop. That area didn't make much. Needle back. In another environment, would this be amenable to a surgeon's transanal approach? Yeah, I think that's, so you can do that as well. And that will be full thing as a section. Yes. So we try to see if we can do it without full thickness. Yeah, I think all that will be a good option. Didn't live very well at that site, but I would like to open that site first and then I will, from the inner site, perform a dissection. Tawany, we'll transition to another room and we'll come back in a few minutes. Okay. We will go to Dr. Nam and team from Johns Hopkins. Dr. Nam. Hi. So we, I just start a mucosal incision at the anal sides. It's over the fold, so it's a little unstable. I use a regular cap, but if I have to, I will change to ST hood to help me get into the submucosal flap easier. Okay. I'm using a Vio3, Erbio Vio3. The cutting current, I use a die cut 3.0 and coagulation current, I use false coagulation, 4.2. That's my mark. And I have wide margin at this size because of the scar tissue. So I don't want to cut too close and have hard time entering the mucosal flap. So to give some technicality or terminology here, I think, Tawany, you are using almost like a bucket method. You're creating a bucket and you're working through it because you did not complete the circumferential incision. Actually, I like modify. I plan to do conventional method, but not opening the mucosa incision at the beginning. There was a slight bleeding after injections. So this is some hematoma there. So after I get in, I'm going to try to go like closer to the muscle. I have not seen muscle yet, but this line is where the muscle should be. So Tawany, based on the challenges you have in keeping the pocket open, you think going underwater can be helpful in making the procedure easier? Yes, thank you. Yeah, sometimes we switch to underwater. So that will help opening the mucosal flap. The problem with underwater, sometimes the distal rectum is bleeding. And if we accidentally cause bleeding, it's harder to find where the bleeding is underwater. So Dr. Saito, Dr. Peterson, would you do different technique? Yeah. Or would you have any comments? Some bleeding, slight. So because it's not a really massive bleeding, I'm going to just use coagulation at the tip. Close knife. If it doesn't work, we're going to use coagulator. Slow down, not completely stop. Dr. Saito, I think you used coagulation at six, is that right? The coagulation you use is stronger than this. We are using for the coagulation. Sorry, stop. We are using first for 5.0 or 6.0. Stronger safety. Open? You can open. Open? Next time you'll have to talk for the safety. Of course. Okay. So we also use endocrine injection at this side as well. I try to get deeper to see the muscle plane. That way we have orientation. But no epinephrine. Yeah, yeah. Dr. Pearson asked why I don't use epinephrine. So because we inject a lot, if we accidentally inject into the blood vessel, it might have the issues. And if it's going to... Some people prefer, so I think it depends on your preference. So there was some data showing that if you put epinephrine increase the risk of post-coagulation syndrome. So actually I stopped using epinephrine completely and call an ESD. And I feel it is much better not to use it. In terms of pain, post-procedure patient do well. And I think there's one study about that. So are you going to complete the circumferential incision or you're- In a little bit, yes. Not yet. Yeah, in a little bit. So as Dr. Rakeshi commented, I should have distance. You see, I have this much distance from the dot. That way I don't cut close to open, close to the scar. Dr. Nam, while you're working on this, we'll go to a lecture and we'll come back to you after. All right, thank you. Dr. Nam, you're on. Hi, we have some bleeding here and we are using cryoglasser. I use the cap of the scope to press on the bleeding spot. Not quite. Yeah, now it's... Move a bit. Okay. After I stop this, I can show you where we are. We have changed patient to right lateral position to further move fluid away from the lesion. We encounter several big blood vessels and there was a bleeding at the initial injection. Now try to see where the bleeding is. Open. And we turn to 11 o'clock. You can see it now. I just flash slightly in order to move it away, but I don't want to put too much water. Otherwise the field become difficult to see. Okay, 11 o'clock. Open. I think it's okay now. Open. Close. Not quite there, but I would say a little bit. That will sometimes be close, stop, slow down. So I see bleeding on the left side. Open. Close. Open. Close. What else? Open. As of close, Dr. Seiter has mentioned that digital rectum has a lot of big blood vessels. Open. Because of scar tissue, sometimes we don't see, it's underneath in between the scar. Okay, take it out, please. That's what left. We already complete circumferential mucosal incision. It took a while to dissect the scar area. We passed that. I think there might be another small scar at the most thoracic on the lesion. So, Wani, you did a great job. I think about the second time, you may also consider to use a snare. You go underwater, you use a snare to complete the resection quickly. That can be an option for non-experts. Yeah, thank you. Yeah, I think if I'm really sure that I can get it out on block, I can turn to the snare. The problem is, I'm not quite sure yet. Okay, some slight oozing here. Open. It's actually stopped, but sometimes we move, use the cap, move the cap around it and ooze a lot, ooze in there. Okay, so. Is RDA available on Cisco? Oh, no, this one doesn't have RDA. We hope we can get it close, maybe next year. Open. So, I just want to make sure it's the right plane. Okay, I think it is. Okay. So, that's the subject of mucosa. I will just quite grasp at that area at the top in a little bit. It's stopped, and then when I move the scope around, it ooze. You can see the muscle plane at the top. Okay. That's a hematoma from the initial injection. Because I don't see plane very well, I'm going to dissect where I can see so that I have orientation. Dr. Saito or Dr. Peterson, do you have any comment or what will you do when you encounter the hematoma and you don't see the plane? Yeah, yeah. So, when the hematoma occur, it's also really difficult to find the line of the dissection. So, in such situation, we should estimate the line from the right side and the left side. And finally, we should speculate the line. Okay. Because of submucosal fat, visualizations are a little blurred. This moment, the final... Oral area is difficult to see, so how about using the microscope again? Thank you, thank you. Yeah. I think, yeah, if you can see, I will try to dissect what I can see at this side. And then, yeah, this is a side that has hematoma. A little bit more difficult to see the plane. Okay, close. But if I think that should be okay to cut. But the problem is now, it's harder to see. Sometimes it's, if you don't see the plane, then it's very brave to cut through the hematoma. In the majority, nothing happens, so. So, let's see. Yeah. I think that's the other side. Open. This, close. That's the other side. Yeah. So, that will help me to see where I can cut. Because this hematoma make it difficult to see the plane. Okay, now, okay, open. There's a... Oh. That is... So, I'm going to follow the line that I think is outside the repressor flap. Okay. Oh, yes. Can you comment on the positioning? It seems like you maintain a good position of the lesion. Did you reposition the patient in between? Yes, yes. Initially, the patient's on left lateral and the lesion is completely underwater. So, we turn the patient to supine. It's better, but part of the lesion is still underwater. So, we close. Close. So, we turn the patient slightly more to right lateral position. This is almost done. Therefore, injection may not really help much because there's no submucosa to hold. Yeah, so the scar area was quite difficult, but the other challenging here is a lot of bad vessel. But after we pass that... Okay. Oh, no. Final cut. Excellent. Doesn't want to come out. Dr. Kashyap, come into the room. Tell me that I have to be done. No, no. Okay. Should be the last one. All right. Okay. Great. Excellent. Congratulations. This is a difficult lesion. Yes, thank you. So, we encountered some bleeding, not severe. We were able to stop it with either the tip of the knife or the crack vessel. There was no muscle injury. This is a scar area here. This one, the one that we cut a little closer to the muscle. So, I'm going to clean the area and use crack vessel to coagulate any pulsatile bad vessels to decrease risk of bleeding. I usually don't coagulate every bad vessel, but the one that pulsatile, or I see the prior coagulation is not adequate, I will add that. And then we plan to use the endocrine spray, hemo spray. It's work similar to regular hemo spray, but it's more controlled because you use air compressor to deliver a spray. And once you apply it at the ulcer base, the ulcer, and it have contact with water, it will form gel and cover the wound. And that way, it stay about three to 48 hours. Has been, it has been studied in, so sorry, let me take a look, in the prevention of post-ESD, open, post-ESD bleeding, close, in the single-arm post-friction study. So, but it's no risk, open, to the patient. So I think it's for close demonstration. And then we open, we plan to close it. Actually, I plan to close it with X-tab to make the defect smaller and followed by regular clip, open, close. Because the distance make it difficult to grab, open, to grab both edge. So it's over the four, I think over two-fold. So let's see, try to see. Let's try to see if any more dark blue cells, open, close. I pull back slightly to concentrate energy, open, close. Close. What's the setting you use for coagulation? Coagulation, soft coagulation, 4.5, open. This is while we close. Open. Because we close, we discharge almost all colorectal ESD home the same day. Sometime in the, like in the rectum, I don't always close. If the patient leave far on hypercoagulation, I close. Open. In the right colon, close. I usually close because we don't admit patient. Open. Close. And there are some study that show that closure after ESD decreased post-coagulation syndrome or even delayed bleeding. Not open. Okay, now this is a great demonstration. And we need to transition now. Do you have any closing remarks? Oh, no, that's all the plan is open. We're going to use a spray and use the, and we're going to close it. Thank you very much. Thank you.

rectal polyp

tubulovillous adenoma

surveillance endoscopy

endoscopic submucosal dissection

scar tissue

blood vessels