So the second you freak out is when your staff freaks out and then like when your staff freaks out Then you freak out more and then it just becomes a vicious circle and then everyone's freaking out and then people hear you from outside So nice Yeah, I think so I mean I think for Dennis and myself like, you know in the third space world, I think It's it's just part and parcel of with the territory. I feel like whenever Something goes south. I kind of picture in my mind Peter Dragunov. He's kind of got the really cool as a cucumber kind of look There you go Nice to meet you guys Philip G from MD Anderson. These are my disclosures I have a couple cases to present I can actually keep going all day if you want I got all sorts of really cool cases and This is really kind of like a day in the life I You know I'm the cases I'm showing you guys with the exception of one of these cases all the rest of these three all happened within the last week So it's really excellent fodder for this course. So case one. We have 54 year old lady who comes in for a colonoscopy She's referred for endoscopic resection She has a very locally advanced sigmoid colon cancer For which she's has involvement of multiple organs in the area and she actually had an upfront diverting colostomy Because she had a large bowel obstruction completed six cycles of chemo and So she's being restaged prior to surgical resection He said a great response to chemo and you know, it occurred to them that oh, she never really had her complete colonoscopy So Yeah So she needs a colonoscopy and she was found to have a large cecum polyp And so she was referred for an endoscopic resection. And so, you know, we kind of think to ourselves Well, what's really at stake here, right? This is a lady who's gonna go for a pretty big surgery kind of saw this was like Sigmoid cancer involving all sorts of stuff in the pelvis. So what's that stake? So this is where endoscopic resection there's significant value to trying to remove these things endoscopically Because if the polyp is found to be unresectable like in other words, you're not able to take this thing out this lady's about to get a total colectomy and If she's able to preserve her rectum, then she gets an ileal rectal and if she's not able to preserve her rectum She's getting an end ileostomy But if you can endoscopically resect this thing She may keep her colon No pressure, of course so Here we are. So this was through colostomy, which is quite fun and For anyone in the room, they kind of know that's a through colostomy is never easy because your scope control is very limited So this is through like a sigmoid slash descending colostomy and here we have the lesion. Does anyone want to comment on this? Don't everyone speak up at once The pattern looks like it It looks like it's probably got some high-grade dysplasia or something in there Depressed areas, maybe some high-grade dysplasia very good, so we'll continue so familiar your familiarize yourselves with this figure as you go through your training because This is actually quite Quite important in terms of being able to categorize polyps that you see or at least big polyps that you see This is what's called the LST or laterally spreading tumor it really reflects so these are not like Pedunculated or semi pedunculated polyps this refers to an entire category of what they consider carpet like or carpet shaped polyps Big carpeting polyps. They're laterally spreading I don't like calling them laterally spreading tumors because then when patients see that they kind of freak out because they see the word tumor But that's formally what is known as and there are several types as you can see here There are granular types which have these little bumps like bumps and lumps and then you have the non-granular types Which are the flat and depressed ones? As you're seeing that right so as I look through this I consider this to be a laterally spreading I consider this is granular. So I see all the little I Don't have a pointer here You see all the little lumps and stuff and you see how some of the lumps are bigger than others So that would be a mixed type LST. So the other thing was the comment that it was depressed So I do notice that fellows, you know, sometimes these are undulating right? And so they say oh, it's centrally depressed But you know, I think it's not it's not always, you know, you injecting you're like, oh suddenly this thing that was Doing this is now like this and it's not centrally depressed. So using that word I think you have to be careful because it's sort of undulates a little bit I think of it as like a city, right? If you look at a city's architecture, you have a lot of buildings, but some buildings are a lot taller than the rest So if you have a bunch of really tall buildings and then you have a central area that has like relatively shorter buildings They're still elevated above the ground. So it's not really depressed. Like if there was like a crater in the ground That's a great analogy So, how are you thinking of I mean what's going through your head in terms of how you're gonna manage this what you're gonna do And ask other faculty how would they approach? So what are your thoughts as to how you're gonna approach it before you show? Right. So for for me, this is a mixed nodular type LST For me when I look at this lesion, so this is a cecum lesion It's very close to the appendiceal orifice. Let me see if I can get this thing to play again So Appendiceal orifice seems to be a big bugaboo in all polypectomy Dinky dinky ones big ones. I mean that's always sort of a big question mark. Yeah, and to me what? You know the decision point here is that because this is so close to the appendiceal orifice I was going to plan to ESD this in order to purposely create a margin My thought process is you know, if I were to take this thing out piecemeal and it were to recur It's one thing if it recurs on the cecum side It's an entirely different thing if it recurs into the appendix where you may not be able to find it on subsequent surveillance That's number one number two the way I saw this was this is a lady who's about to go for surgery and After surgery depending on what they find at the time of surgery. She may be untouchable for quite a while So she may not be able to have another colonoscopy for a while The next time you might get a chance to scope her might be like a year or so down the road at a minimum That's assuming her surgery goes well. And as you saw there's a lot of organs coming out So chances are it may not go so well And so my thought process here was I'm gonna do something where I'm going to Try to reduce the risk of recurrence as much as I possibly can So that there would be less of a chance of it recurring during the year plus that she's not going to be scopable Dennis so just to comment on that For for the fellows, this is a very difficult case. This is in the cecum through a colostomy 3-quarter circumferential, right? So Philip is gonna demonstrate an ESD in this case But this is not going to be the standard ESD case for most people I agree with some of the things Philip was saying. I mean overall it didn't look like there's invasive cancer per imaging show Could a piecemeal resection being a reasonable approach? I think so now if you have the skills and the ability to do the ESD in the safe and efficient manner That's completely fine, but this is not going to be an easy ESD for most people So piecemeal resection in the absence of some mucosal invasion is a reasonable approach Personally her situation of I mean, maybe she can be cured. I don't know. Do you know do you spend? I don't know how long it took you but it would take me a while even piecemeal, you know to take this out You could see the AO it didn't look to me quite like it goes in there So, I don't know that I would be so concerned and you know I think the majority of the world does this, you know, and if she had recurrence, okay If she had recurrence like I'm not sure that's quite the biggest deal ever, but what Peter I agree actually with both arguments that were made Of ESD versus EMR But Your social should keep in mind the price to pay if you perforate In this particular case It's well above average price to pay and that will in my mind favor me towards EMR And it's not ESD versus EMR. You can use a combined technique You can take the appendix or orifice site with ESD knife to secure the margin on that side or do a full circumferential Incision because of incision around the lesion with ESD technique and then do the middle with a snare EMR so it's not either or necessarily Can you comment on your choice of distal attachment cap and the location of your venting hole in relation to where you are in the colon So this is a Fuji St. Hood, which is basically it's a tapered cap. It's a it's a long cap. It's tapered at the end It is purposely built for tunneling It's one of those things where you know, you guys probably saw with the poem. It's a it's a it's a standard cap So, you know, you actually have to make expand the submucosa quite a bit in order to enter the third space It's a tapered cap. So, you know you sacrifice vision so it comes at a cost of losing peripheral vision and in certain cases Especially if the cap gets cloudy or if it's fogged up it can get extremely annoying But for cases like this where you're trying to gain access into the submucosa as soon as you can Or as much as you can actually can be very useful So yes, very valid point and the whole point of showing this case is not to show off or anything But really to kind of open your mind in terms of different approaches, right? Because this is what Dennis alluded to as the cognitive aspects of third space endoscopy It's not just about doing the technique or knowing how to do it or having the ability to do it but really kind of thinking it through in terms of deciding how are you going to use the tool set you have and As Peter was mentioning it doesn't have to be a full ESD It could be a yes You could you incorporate elements of ESD into your EMR for specific purposes like for dividing it away from the appendiceal orifice This is absolutely not a beginner's ESD case This is a case that gets pretty interesting and you know with ESD Ashley was mentioning earlier You know, I was like, what do you learn first? Do you learn poem first or do you learn ESD first? And I probably would submit that for most people they learn poem first because ESD every lesion is different And with this one you can see right off the bat I had a bit of a misfortune in just injecting this lesion on the very first injection I hit a small vessel in the mucosa. And so I dealt with this vessel Basically for most of this case, so for most of this case I was forced to follow this vessel and all of its beautiful black brown non blue staining that it left on the in the third space and I was just basically kind of forced to deal with this corner for much of the case. I Could see the vessel I'll disclose that a little later But you know, it's like you're just kind of chasing this thing and of course you realize that you know the deeper you go the higher the risk of perforation to Peter's point that the at the Risk of perforation is probably a little bit above above average here But eventually, you know with a bit of persistence and maybe stubbornness or stupidity or whatever you want to call it So we eventually make our way through here And here you can see the vessel coming to view for the first time buried amongst all the other garbage that's there And you can see it's very thin sliver of submucosal space and so, you know, this is an injectable ESD knife It's called this is a pro knife It's an injectable type knife where the injection comes through the middle of the knife And so I'm very liberally injecting as I go along because I absolutely do not want to deal with a non lifting submucosa here The only thing that this lady had in her favor was that no one has messed with this polyp before just again because no one Has ever been there before? So that was really the only advantage that I had. So anyways, oops, I really want to Show this part. So so I'm dissecting I'm dissecting and everything's going pretty well, actually You know, so I'm you know, this is a very difficult corner of the cecum, by the way. It's like one of the extreme top right corner. So I'm dissecting. And here, this is, again, as Schaefer asked the question, what kind of cap is this? So it's the Fuji ST hood. So everything seems to be going pretty well. I've actually used a pediatric colonoscope. Things are going pretty well. I actually, as you can see from the blanching on the other side, I've already almost reached the other side of the polyp here. And the way to use a pediatric colonoscope that I have is that you can't suction. I guess suction's not a big thing. Uh-oh. Oh, shit. Oh, that's not good. And so this is how I view endoscopic resection. Is that a Texas thing? Because I don't think they'll approve that. Yeah, it might be a Texas thing. So this is what the cap looks like. And there is a weak point in the cap, which is the area where the soft plastic turns into hard plastic. And yeah, if you're really banging against a sharp corner, you may actually eventually sever the cap. And so I kind of thought to myself, oh, no. It took a while to get here. This is not too easy. Maybe we'll try doing this without a cap for a while. So maybe we'll just kind of go without a cap for a little while. The thing with the pediatric colonoscope is if you want to suction, you have to do something where you're trying to suction things down to get a snare around it. If you have a device down the scope, it doesn't work very well. So as nice as sometimes it's to have the flexibility of the peds, and plus you're adding a cap on, and it may make it bulky, I don't love it for EMR. It's not great. And so here, without a cap, I decided to take advantage of the appendiceal orifice and just kind of use this time. I knew my time was limited. I knew that at some point I was going to be forced to just put a new cap on. But I figured while I was waiting, I might as well try to finish dissecting as much as I can or finish incising. So this is, again, separating it from the appendiceal orifice itself. And then here, eventually, it just got really annoying. So I said, whatever, we'll pull the cap. We'll pull the foreign body out. So it'll officially become a foreign body retrieval. So yeah. Is there a stricture in the sigmoid? No. Oh, because it's diverted above it. Well, I mean, because it's colostomy, right? So it's a nicely patent colostomy up above. So now we have a cap back on. And you kind of appreciate the advantage of having a cap at this point. So here goes the rest of the section. And you can kind of see we're just slowly peeling this off. So this takes a little bit of persistence. Just kind of slowly peeling this off. I will admit that I just kind of did a pretty minimal edit of this video. And in here, we kind of have the final portion of this thing coming out. Sorry, what was that? About to evaluate the legitimacy of the clams. Yeah. There's a couple areas where I briefly touched the muscle. So in the colon, you're already kind of taught cecum's a pretty thin wall. So I don't take my chances. If I even barely dent it or barely touch the muscle in any location, I'm putting a clip on just to make sure the area doesn't fully tear open. And here you go. So that's the end of the resection there. So the follow up here. So she did well. 65 by 60 millimeter specimen. Took me an hour and a half. Sorry. Pathology was quite favorable. It's high grade dysplasia, intramucosal carcinoma. We had negative margins on this lesion. And this is something, again, the cognitive aspect of third space endoscopy, right? So I was surprised at the degree in which a lot of our fellows, or even advanced fellows, do not know this. But AJCC TNM staging. So intramucosal adenocarcinoma is considered T1 or T1A for the esophagus and for the stomach. It is not considered T1 for the colon. So for colorectal cancer, intramucosal carcinoma is a bit of a misnomer. It's T0. It's carcinoma in situ. So this is actually considered a curative resection. And she did end up getting surgery. She had a robotic anterior pelvic extension. She lost basically all of her pelvic organs, but she kept her colon. She kept her distal rectum. She did not need a colostomy. She was seen in post-op about, I think, like just a couple of days ago. Because this case just happened like two weeks ago. And then she immediately went to surgery like several days later and had surgery done. And she did not need a colostomy. She's out of the hospital. She's having normal bowel movements. So I'm actually fairly surprised at how well she's recovering. So the key lesson here is that it's worth resecting if it actually does make the surgery smaller. So case two. So this is another one. So a 66-year-old guy. Yes? You have to close the whole defect, mucosal defect, or? Great question. So I left it open. So this is a point of ongoing debate in the third space world in terms of, do you close these? Do you leave these open? My bias has always been, I personally feel like I lacked the technical skill to close this. So I left it open. I know there are some people who can actually get overstitched to the right colon. And they'll actually sew up the right colon. I will confess, I do not possess the ability to do that technically. Yes? It's a practical question. One of the difficulties that I often face when using a long cap is navigating it through a tortuous sigmoid and getting it to the right colon. So are there any longer long caps that are easy to do than the others? And what are beginner tips to sort of get there? Because if I don't get there, then the scope gets taken away quite easily, quickly. Absolutely. So there is a bit of an art to getting a long cap to the end of the colon. This becomes even more relevant if you were to ever do full thickness resection with the full thickness resection device to the end of the colon. There's a lot of patience that's involved in it. So I would say just be patient, persist, try not to put too much air into the colon. Because this is one of those cases where the longer you make the colon by distending it full of air, the more likely the scope's getting taken away from you. Because you're actually going to make it difficult to reach the cecum in a short position. Amazing resection. Before you move on, can you just make some general comments about how you approach appendiceal orifice involvement? Yeah, excellent question. So I usually will remove things if it's only encroaching on the appendiceal orifice. I don't like chasing lesions into the appendix itself, again, because I feel like if it recurs, and it recurs into the appendix, then you've left yourself with a situation where you cannot properly survey the patient. There are certain cases where you may be able to resect an appendiceal orifice lesion if the patient has had a prior appendectomy, because then they don't have a vermiform appendix. But if they have never had an appendectomy, they have a vermiform appendix, where the appendix could be several centimeters in length. If I cannot properly identify the bottom of the appendix, I will abort the case, and I'll send them for surgery. So when you do this, I heard you're the leading FTRD resectionist in the United States, according to Ovesco. So do you use FTRD for things like that? I don't. For appendix, actually, that's one of the very few FTRDs that I don't do. And it's, again, for the same reason, because if they had an appendectomy, I would consider that. But if they have not, I would rather not risk it. It sounds theoretical, but I wouldn't want to risk disconnecting the appendix, especially if there may be adenoma within, because now you would have a free-floating appendix just chilling somewhere in the peritoneum. And if it grows adenoma, that's problematic. So if you put your forceps in, and you kind of probe around there, and you think you see the edge of the polyp, are you fine with just snaring that out? Because we get a lot of referrals for anything nearing the appendiceal orifice. What? Yeah, be back. This might be heresy, but I think in GI, we've gone overboard thinking that adenomas are really disease. I mean, you can leave an adenoma. For years, for CT colonography, six millimeters, you leave them. The risk of it progressing to cancer is, if it's my appendix, you're not going near it. I'd rather live with the adenoma and take my chances for 10, 15 years. Oh, I'm joking. If it's my appendix, I'm going to find a general surgeon. I guess a point for the fellows. I think Phil brings out a great point, right? Where the history of whether the patient has an appendix or not an appendix come into play for that. And I think sometimes we don't do that enough, and we just say, oh, there's a polyp in the appendix. It's going to bring up the EFTR. And if you look at the data on the rate of complications with this device, it can be as high as 20%. It's about 17% of complication rate, particularly if the appendix is in situ. So that's a considerable risk that you should take into account. So I share what Phil said. Yeah, Dennis, actually, thanks for pointing that out. The recent Dutch experience has clearly stated that it's probably the largest experience with EFTRD in the realm of the appendix. I think it's right around the 15% mark for appendicitis, as well as for perforation. So not to say that although this exam was through the ostomy, so the sigmoid is not an issue. But getting that EFTRD device through difficult sigmoids, and most of these patients have difficult sigmoids. Some of these are older patients. And so that's not to be taken lightly. But there's another study came out a few years ago that showed that if the adenoma creeps into the channel, it's not worth pursuing. So unless, of course, you can tease it out. And one of the tricks I use is to inject a little bit of saline distally that actually brings it more proximally out. And then cold snaring is a safer technique in that case. But if you cannot chase the end of the lesion into the tunnel, the data is pretty clear that needs to be dealt with differently than EMR or ESD. Just piggybacking on Amitabh's point, Phil, I'm sure your practice is similar to mine in that they give these amazing chemotherapy cocktails to people with rectal cancer, and sometimes you go to remove the CEQL polyp and it's gone after they've received chemotherapy. And that's kind of an area that I think is lesser explored in our field. And for those who kind of wonder, was it really a polyp to begin with? Yeah. I just wanted to piggyback on what everybody's saying. I agree that with adenomas involving the appendix, it's very tricky, and I don't want that 15 to 20% risk of appendicitis. I think another tip besides injecting the distal wall is underwater infusion. So if you really want to assess if the appendiceal orifice is involved or how deep it's going, you want to give it a chance to see really if it's something that you can resect. I like to just infuse the entire CEQM with water, and then you can get magnification, the lesion can float up to you, and you can see if you really have a margin that you can kind of go after, or if it's really deeply embedded and you should just walk away. That's a great idea. Sometimes injecting screws you, too, though. You inject it and the whole thing goes in, and then you're really stuck. So I like the idea of the water. I'm the biggest fan of water ever, for all things water. And my fellows know this. There's usually puddles in places. But I think that's a great idea, Julie. Because sometimes injection, you kind of know the concept of what we're trying to do, but sometimes it doesn't work. The appendix also doesn't inject very well. So I actually really like that point. I have a great video I'm gonna show you, Phil, that I just did two days ago. I sent to Amitabh. Mucin coming out of a polypoid-looking thing at the appendiceal orifice. Concerning. I don't know. Is it not? All right, so since we're limited on time, I'll actually, you know what? Of course, the director is a call. Would you guys like to see another ESD-type case, or would you like to see an FTRD? Well, Dr. Chalk has a case. Dr. Chalk has a case, okay. Can you give me the boot for a second? Yes, no problem. But maybe, can you leave your computer there? Yeah, yeah, yeah, I'll sit up here. Okay.

endoscopic resection

cecum polyp

sigmoid colon cancer

chemotherapy

colostomy

pathology