So first up is Uzma Siddiqui from University of Chicago. Thank you to the ASG and our course directors for inviting us. We have six interesting cases on colon resection techniques, so I'll just jump into my first one. This was a patient referred to me for an incompletely removed cecal, sessile serrated polyp, and I was asked to finish the resection. So when I'm getting this referral, I'm automatically thinking, okay, this has been previously manipulated. It's going to most likely be scarred and potentially be more difficult to remove and or have potential complications. So you can see the remaining polyp there in the cecum, and I did do a submucosal injection. Surprisingly, it lifted very nicely. I thought things are going very well, and then I put my snare around it, and this is a 15 millimeter snare, which is my usual go-to. I did submerge it under water, and then I start cutting, and this is real time. So it's taking an awful long time to cut through this tissue, and at this point, I'm noticing when I move my snare back and forth, the polyp is not separating from the wall, and I'm already getting very anxious that potentially I'm going to have a perforation on my hands. So finally, we get it off, but I'm committed, so we're going to finish this resection at this point, and you can see there is a target sign right in my resection base. So that means I've injured the deep muscle wall. This needs to be closed right now, otherwise your patient's going to come back with peritonitis and need surgery. First though, I want to finish my resection. We have a clean field. The patient had a good prep. There's not a lot of liquid in my field of view, so I don't have to rotate the patient, and because I'm in the right side of the colon, I'm going to go through the scope clips. Some people would suggest maybe an over-the-scope clip, but that requires you to take the scope out and come back, and you can see here on my specimen, I have a mirrored target sign. So this patient did well and went home the same day. And then this is my next case. This was a 50-year-old female referred for resection of a sigmoid lesion. She actually had a right-sided colon cancer earlier, found to have Lynch syndrome, and underwent a subtotal colectomy. And the outside GI doctor was doing a surveillance procedure and found this polyp. So you heard about all the different types of polyp classification systems. Sometimes they're hard to remember, all of them, but I think, you know, looking at this polyp, you can tell that there is an amorphous appearance without obvious pit patterns and abnormal vascularity, and those findings plus her history should make you think, okay, this is very suspicious for a possible cancer, and for that reason, when you resect it, a simple polypectomy may not be enough. You want to get deeper into the submucosal layer at least so you can get adequate histology. So they did a polypectomy and then were surprised that the pathology came back adenocarcinoma with a positive margin. The patient refused any further surgery, so again, was sent to me. I went in and I saw there was some residual polyp. There was a clip applied and also, you can't see it in this view, but there was also tattoo there. So the options for resecting at this point, you think, oh, maybe ESD, but because of the previous manipulation and tattoo, it's going to be potentially scarred down and difficult to resect, and since it was a cancer, I want to get as much tissue as I can, so I went with a full thickness resection. So when you put the full thickness resection device on, it's a long cap and it's hard to visualize your lesions, so you want to mark the borders first. And then I took off the clip and now you see the full thickness resection device in place. I'm grabbing the tissue with a grasper and then you pull it inside the cap, making sure that your grasper is well within your cap. Then you deploy a clip and then you have a snare that's going to resect the tissue. And so we did get a full thickness resection, and on pathology, there were a small foci of adenocarcinoma, but all of our margins were negative. All right, we'll move on to our next cases.

Uzma Siddiqui

University of Chicago

colon resection techniques

sessile serrated polyp

full thickness resection