ASGE Postgraduate Course at ACG 2022: Expanding the Scope of Fundamental and Advanced Endoscopy | October 2022-15 Rex_Choosing EMR techniques for maximizing success

15 Rex_Choosing EMR techniques for maximizing success

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In this document, Dr. Douglas Rex discusses various techniques and considerations for maximizing success in EMR (endoscopic mucosal resection). He highlights some common problems encountered in polyp resection, including size, flat shape, access, fibrosis, and the number of lesions. To address these challenges, Dr. Rex suggests using the Cap technique for size issues and fibrosis, avulsion in fibrosis, and water for access and exposure.<br /><br />He also discusses preparation of resected lesions for optimal sectioning in pathology, recommending bivalving pedunculated lesions through the stalk and pinning non-pedunculated lesions flat against a surface.<br /><br />Dr. Rex also mentions the use of cold snaring for debulking multiple large polyps, as well as cold EMR for massive homogenous G-LSTs (giant laterally spreading tumors). He emphasizes the importance of considering the size, flat shape, access, fibrosis, and number of lesions when choosing the appropriate technique.<br /><br />Some selected issues for EMRists, including dealing with SSLs (sessile serrated lesions), large serrated lesions, and exposing vessels, are discussed. Dr. Rex suggests using cold EMR or cold piecemeal EMR without injection for SSLs, avoiding injection for large serrated lesions, and leaving exposed vessels alone. He also recommends clip closure for EMRs on the right colon measuring ≥ 20 mm and performing real-time STSC (submucosal tunneling and scarring) margin treatment.<br /><br />Finally, Dr. Rex discusses the implications of the NICE 3/Kudo 5 guidelines. He suggests using all-cold techniques for serrated lesions, cap or avulsion for fibrosis, cap and retroflexion and underwater techniques for access, cold techniques for debulking and large lesions that cannot be closed, underwater techniques for en bloc resection up to 30 mm, and STSC after all hot piecemeal EMRs. He also recommends clip closure proximal to the splenic flexure for lesions measuring ≥ 20 mm and performing closure of left-sided defects with the X-tack technique.<br /><br />In summary, Dr. Rex provides a comprehensive overview of techniques and considerations for maximizing success in EMR, addressing various problems encountered and offering specific recommendations for different scenarios.

Keywords

EMR

endoscopic mucosal resection

polyp resection

Cap technique

fibrosis

water technique

pathology

cold snaring

sessile serrated lesions

NICE 3/Kudo 5 guidelines