All right. Good morning, everyone. Thank you to the course directors and ASG for this opportunity to share with you some colon EMR cases. So I figured a lot of times at these conferences you always see the best of the best, right? You'll see the best cases all done in 30 minutes or your pizza is free. No disclosures, by the way. So I figured I would like to show you a case actually from the very ancient archives when I first started EMR. And in fact, I am a testament to the ASGE STAR program. I was very honored to have been selected for the very first inaugural class. In case you guys are listening in the back, I'm still looking for the inaugural class photo. But this was 2014. So you can see we're using sort of, you know, standard def scopes. And I will actually, I want this to be as instructive as possible. So I'm going to stop right, pause right there. That actually was a focus of high grade dysplasia. You know, many years after the fact, of course, you know, it's instantly apparent. But at the time when you're in the zone, you're very sort of anxious, you know, you kind of just, yeah, sure, sure, sure. And so the other thing I would like to highlight is I used the colonoscope, except this was actually in the rectosigmoid location. This becomes very unwieldy. And so this is one of the teaching points is to use the right tool for the job. Now, in obviously many years later, in a location like this, I would have chosen, for example, therapeutic upper endoscope, because it is much easier to navigate and negotiate in that low of a location. And so what we do is we like to inject, and I'm very honored to have Dr. Dragunov as the, one of the course directors. He likes to describe this color, sorry, this color as Carolina blue. It never occurred to me what Carolina blue was. And so I instantly Googled it. And so this is exactly what I did. I drilled my nurses to, you know, make that shade of blue. And this is also an important part. So again, when you're starting EMR practice, it's important to know, you know, to get the snare to the right margin. We drilled this down very importantly, because otherwise, it just becomes very sloppy and you end up having to clean up afterwards. So fortunately, I did recognize that before. And so again, you know, as you can see, it's almost like, you know, baby taking their first steps. You know, I was able to reposition the snare. And if it looks somewhat painful in the back of the room, because it was incredibly painful. And in fact, notice here, even the scope handling and the snaring is not ideal. And I show this be precisely because, you know, I was you, right? When I first started the practice, you know, I really want to encourage every single audience member who has the passion to reach for the stars. Sorry, that was a little plug for the ASG star program. You know, and even here, you can see that the snare position was not optimal. You know, I was way too far. And the snare was way too far out into the distance. And so now it was a safe, successful procedure, but there's definitely room for improvement. And just in the interest of time, you know, we want to sort of again, this is right there. You know, this is not if my fellows, you know, do this, you know, I will politely give them constructive feedback compliment sandwich. But notice how the tip is down, the snare is up, there's a high likelihood of posterior aspects of the of the tissue flying off. And that's basically what happened. But long story short, it was a safe, successful procedure, no cancer. And on follow up, you know, this individual did well on the long term fall. But again, this was back in the very early days of my practice in 2014. So this is a little bit more recently. And you'll notice the technique has changed, obviously, the definition of the image has improved. And when you're dealing with a difficult location, such as this, for example, it is critical, sorry, it is critical to have a detailed inspection. And so what we end up doing as, as you notice there, you always want to, if possible, intubate the terminal ileum first to make sure it's not actually encroaching into the terminal ileum. And it wasn't at that point, it was close. But, you know, just like in real estate location, location, location, you always try to resect a mark, I'm sorry, and inject in a so called a dynamic injection as espoused by Kaltenbach and Saticno. And this is very important because and this is actually a very important part of the this video. So I look at EMR sometimes like docking a boat at port, full disclosure, I don't have a boat, I don't have a port. But there's many subtle maneuvers that you may have to do. Sometimes you have to suction, sometimes you have to go close, sometimes you have to torque a little bit, sometimes you have to do both big and small wheels, whatever it takes to achieve that proper axis of orientation so you can facilitate the cut. And sometimes it's the use of the appropriate snare, which is stiff, and you see this so called blue out, right? Don't be alarmed. In fact, I love using the blue out technique in order to make sure that you get good tissue purchase. Sometimes you may see fat at the ileocecal valve, please do not be alarmed. One big clue is that you have blue staining sub mucosa underneath. And if you're not sure, as you can see, in this case, you can also inject underneath to confirm that you are in the proper plane. And with that, I will stop. Thank you

colon EMR cases

therapeutic upper endoscope

specific shade of blue

EMR practice

learning experience