ASGE Postgraduate Course at ACG 2022: Expanding the Scope of Fundamental and Advanced Endoscopy (On-Demand) | 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 K. Rex discusses various techniques for maximizing success in EMR (Endoscopic Mucosal Resection). He highlights the challenges faced during polyp resection, including size, flat shape, access, fibrosis, and numbers of lesions. <br />To address these issues, Dr. Rex suggests the use of different techniques such as the Cap Technique for fibrosis and flat disease, avulsion in fibrosis, and water for access and exposure. He also mentions the use of cold snaring and debulking for multiple large polyps. <br />For optimal sectioning in pathology, Dr. Rex recommends bivalving pedunculated lesions through the stalk and pinning non-pedunculated lesions flat against a surface. <br />In cases of massive homogenous G-LSTs, Dr. Rex proposes the use of cold EMR. <br />On the topic of selected issues for EMRists, Dr. Rex discusses the use of two approaches for SSLs (Serrated Sessile Lesions) - cold EMR and cold piecemeal EMR without injection. He also touches on the importance of electrocautery (cutting or forced coagulation), leaving exposed vessels alone, clip closure for ≥ 20mm right colon EMRs, real-time STSC (Submucosal Tunneling and Surgical Closure) margin treatment, and left-sided defect closure with X-tack. <br />Dr. Rex concludes by discussing the implications of NICE 3/Kudo 5 guidelines, suggesting that serrated lesions should be approached with a cold technique, fibrosis should be managed with either cap or avulsion, and access should be facilitated with cap, retroflexion, and underwater techniques. Additionally, he highlights the benefits of debulking and underwater techniques for larger lesions, the use of STSC after hot piecemeal EMRs, and clip closure for larger lesions proximal to the splenic flexure.

Keywords

EMR

polyp resection

fibrosis

lesions

Cap Technique

cold snaring

debulking

bivalving

Serrated Sessile Lesions

clip closure