What I'd like to do is go on to demonstrate to you a case of a large polyp that I mentioned. If I came across a large polyp, I would bring the patient back for another procedure to do a dedicated resection. And this is a patient I did several years ago, and we have a video that demonstrates the endoscopic mucosal resection technique. And during this, we use many of the devices that you just saw. So we'll go ahead and run that video. And so what you can see is we're first assessing the lesion. We're trying to get an idea of how big it is. It's actually down in the cecum. That structure at the top was the ileocecal valve. And we're using the tip of the snare, an electrocautery, to mark the outlines of the lesion. Now what we're using is a needle, an injection needle, to inject some dye and a solution underneath the lesion to lift it away from the wall, like we demonstrated in the lecture. Here's our snare that's going around the part of the polyp. We're not going to be able to resect this all in one piece. This will require resection in multiple pieces because of the size of this polyp. If we were to try to attempt to resect that in one piece, we'd have a much higher rate of creating a hole in the wall of the colon called a perforation. And so we're doing this in a piecemeal fashion, trying to be as complete and as organized and deliberate as possible, ensuring that we completely remove this lesion, making sure we don't leave any residual polyp. So here you can see one piece after another we're resecting. You can see we are leaving these pieces in there until the end, and we will collect them all at the end. We're just going to move that piece out of the way so we can assess what's left of the polyp. We're injecting some more dye to lift the lesion up because sometimes that dissipates with time, so we have to repeatedly inject. And after I resect this piece, you'll see a little bit of bleeding. And that bleeding is dealt, see the pulsating bleeding there? And we deal with that with injecting some epinephrine there to stop it and applying some coagulation. We're still injecting some more medicine to lift up the residual polyp, using our snare to again resect piece after piece after piece. We still have a little bit of polyp left in the middle there that we have to deal with. We want to make sure to resect all of this in one setting. We don't want to do this in multiple settings because it'll become scarred down and much harder to resect if we try to do this, if we don't get it all done in one setting. And so here we're almost done, and we've got an APC that we're using here to coagulate vessels and also to just treat up the edge of the lesion to ensure that if there's any microscopic disease at the polyp edge that we're ablating that and therefore decreasing the risk of residual polyp when we come back six months later to look at that. We could then use clips to close that, and we typically would. In the interest of time, we won't demonstrate that particular part of the procedure. So do we have any questions about devices? You know, Dr. Tierney, one of the other questions that we commonly get after this is, is bleeding usually the most common adverse event you're managing, or does it just depend? So we have a lot of different adverse events that can happen during gastrointestinal endoscopy. In this particular procedure that we just performed, endoscopic mucosal resection, the bleeding rate can be as high as 5%, 10%, maybe even higher depending on how big the polyp is and where in the colon it is. And that bleeding can occur up to two weeks after the procedure. So that's why we have to educate our patients, tell them what to expect, and if they do have significant bleeding with a lot of red blood in their stools, or even black stools when it's this far up in the colon, to come to the emergency room so that we can manage them and make sure that we address the bleeding sooner rather than later. The other main complication that we would, the most dreaded complication, as I mentioned earlier, is perforation. And the risk of perforation is much lower than the risk of bleeding. But when it does happen, it's often a little bit more severe and harder to manage endoscopically. We can manage perforations endoscopically if we diagnose them early enough. If the patient were to go home and experience a delayed perforation, that's a much more challenging situation that often requires surgical intervention to correct.

endoscopic mucosal resection

large polyp removal

cecum

bleeding management

perforation risk