So, we have a case of a rectal polyp. It's a 59-year-old female with a history of hypothyroidism who presented with intermittent rectal bleeding and change in bowel habits over two months. She was found to be FOBT positive. And as you can see, a colonoscopy was pursued, and a 3 to 3.5 centimeter laterally spreading tumor with a granular type morphology was seen in the distal rectum, right at the level and very close to the dentate line, as you can see in this image. No biopsies were taken to facilitate future endoscopic removal. The plan is to perform a sigmoidoscopy with ESD. And over to Dr. Nam. Okay. So, I'm in the rectal test position. So, I'm in the rectal test position, and you can see left lung, right lung, right lung. By the way, now I'm using an actual H190. This colon does not have a magnified function. Do you hear me okay now? Yes, we can hear you, and we have your endoscopic view. Okay, fine. So, I'm using the actual endoscope. This one doesn't have a magnified function, but has an excellent bending station up to 220 degrees. You can see a large rectal lesion, right here at the dentate line. This lesion, you can see through this portion here, that portion, and looks like a cell component here, which is blacker than what's in the middle. I suspect that this lesion might be from the lesion going in and out. That might cause a lesion. Under NBI, I do not see the area of new lesion. Sorry, the magnified view. Dr. Nam, sorry to interrupt you, but we are having some technical issues with your audio. We cannot hear you well. Yeah, sure. Amrita, let's just take this first question from Dr. Pankaj Dhawan. He's asking for a sigmoid or esophagus, or with severe submucosal fibrosis, sometimes an anterior, and sometimes better. What is your take on that? I think it all comes down to finding a plane that works. I find that the most important thing is not trying to do a very long myotomy. I think those patients are usually very dilated, and just a distal, shorter myotomy is better. For me, personally, I start on the posterior side, knowing that it's going to be a short myotomy. I do try to take an approach that will allow me to do a myotomy of part of the sigmoid portion of the esophagus, so as to get rid of the turn in the muscle. But I think what is a really important point that we need to highlight from Moeen's case is that he made three attempts. He didn't just struggle at the first entry site and keep going. I imagine, because he hadn't been doing it for very long, that as soon as he recognized that there was not a good submucosa to work with to create that tunnel, that he aborted and moved to another site. It doesn't have to be exactly opposite, anterior, posterior. You can really look at the mucosa, have an assessment and predict what's the underlying fibrosis. But the important part is to move quickly before you cause a perforation, because you're struggling through the fibrosis, and to go ahead and make it shorter. Start a little bit more proximal in anticipation that you might need to create another tunnel, as long as you have enough room. I think that's a really important point, and it takes experience to recognize that. I fully agree. Just a couple of points to add on to what you said. One can even need to do, if it's needed, one can do a lateral tunnel as well, not just anterior or posterior. Having said that, usually because of food and the fluid accumulates on the posterior side, the mucosa is relatively a little bit cleaner and nicer to work with sometimes. The other point is, very often the food really stagnates at the distal part of the esophagus, and therefore, although the myotomy has to be short, sometimes you may just find that the mucosa, a little bit more proximally, is better to work with. You can create a slightly longer tunnel, but still keep the myotomy short. That's something that sometimes you have to do that. We showed this patient earlier. This patient is about three centimeters. Lateral strength tunnel with sensor components. It's mixed granulat, not granulatite. This is a sensor component here. We did not see deep condition, so we decided to perform a local surgery. We also identified a small hemorrhoid, so I think she has a very good idea of hemorrhoids. We did not have to do marking for recognition, but because we are working at a very narrow area, so I did marking in the first week of the donor. I already dissected from the female side. My plan is to dissect from the female side, because I think this is the most difficult part. Usually, when we do colonoscopy, I usually start on the far side, but except for this location. Again, I think we've lost Sawani's audio there. I think what she's stressing is that she does start on the anal side, because she anticipates this is the more difficult side. We heard that from Vivek as well. There was some bleeding during initial dissection, not severe, just oozing, because there are a lot of big blood vessels in this area. We did not have to change to coagulation forceps. It all has been coagulated by a prosthetic of the dual knife. You can see here, this is anorectal junction, and this is what we have been dissecting. What settings are you using? I use swift coagulation effect 4, 40 watts. From mucosa incision, I use dry cut effect 3, 40 watts. The key is in this location, when you start at the anorectal area, do not cut too deep, because you might hit blood vessel underneath it very easily. I cut very superficial until I expose closely some mucosa, and then cut deeper. You can see muscle here, and I try to cut deep until I see muscle, so that I can remove, go underneath some mucosal blood vessels. Savani, are you planning to perform pocket kind of an ESD? Conventional ESD by... Open, please. After I dissect this area near the dented line, then I'm going to cut from the proximal side in the retroflex position, and then finish the rest of the dissection in the forward view. Close. I think pocket creation is another good option, because it keeps the scope stable when you do dissection. Open, please. I inject to the knife, and then continue to cut. Is this a dual knife? Yes, this is a dual J 1.5, and you can inject to the knife. The injection comes through the sheath of the capital, not at the electrode. There's some slight hematoma here from blood, so it's a little bit more difficult to cut. When you use the knife for coagulation, are you keeping the knife out, or do you close the knife and use the tip of the knife? Usually, close to the tip of the dual knife, you have the larger area of coagulation to coagulate blood vessels. I think this top part almost comes out completely. This is the retroflex that we showed earlier. Do you anticipate using any type of injection? I usually use gravity for rectal ESD. For example, this patient, when we start at a lateral position, we saw half of the lesion was underwater. I turn the patient slightly almost to a prone position in order to move that water pool away, and if I need to, I will change to supine or right lateral position to get the gravity. First, I think because this lesion is very close to the anal canal. The traction device, it depends on what device we talk about, sometimes it's difficult to get it in. Second is in the rectum, the rectum is quite easy to change position to get the water away. Can you remind us of what solution you're using? At the anorectal junction, we usually inject a small amount of lidocaine, 0.5 lidocaine, mixed with hetastats and methylene blue. But I plan to also use orice gel when I dissect the more proximal area. But we cannot mix that. We cannot mix that in the orice. The area that I already cut near the dented line, we use hetastats mixed with lidocaine and methylene blue. As Dr. Haber mentioned about endoscope, this endoscope is very flexible, can bend 210 degrees, which is very important when we do ESD, because most of the procedure I do, I retrofix. So we have to carefully select open the endoscope. Can you just remind us which endoscope you're using? GIF-H190. This one doesn't have a magnified near-focus function. So the scope, at least it's slightly thinner than the one with near-focus function. But the bending section is really nice. This scope is, I think, a little bit thinner and it's also more flexible. So it really bends much better than the HQ scope, which has the magnification function. But once you actually start doing the dissection, you don't need that magnification function. You can let go of that and probably choose a scope which gives you more maneuverability. I think I agree with Dr. Nam on this. And when we do dissection, I encourage those who are learning to try to practice adjusting scope control with your left hand open without letting go of your right hand to move the small dials, because if I let go of my right hand, I will fall back immediately. So let's clarify on that. So you are holding the shaft of the scope as well, or do you have someone helping you? Yes, I hold the shaft of the scope and I use two fingers on my right hand to control the knife. So if you can zoom in at my hand. Maybe we can show her hands on the scope. That's one way I do, but what I think will help with the facilitator procedure is to control left, right and big or small view of your scope with your left hand without having to let go of your right hand to do two hands technique. Now I just use the talking and slight movement of the dial. This is a little sticky. Close, please. Okay, let's inject a little bit more. Open. So I expect that the patient probably going to have some pain. Close. We send the patient home with pain medication. I hope she doesn't need to use it, but we have it ready. You know, between these two cases and it's been my experience as well, this is a novel way to treat hemorrhoids when you have these large vessels. Yeah. I think that's about the surfaces we need here. There's a little bit of pulsatile here. So I would like to do pre-calculation. Can we change the setting, please? No, no, no. Hang on one second. Change to false calculation one seven. If it's big and pulsatile like that, I would like, instead of using the knife to cut directly, I would usually try to do pre-calculation by touching it, give some slight tension and use a very low setting. I use false one seven. This technique described by Dr. Toyunaga. It decreases the need for changing instrument to pre-calculation process. Is it possible for us to see your unit's numbers right now? This is a very important point. It's a beautiful technique but it's important to know that the settings do have to be changed. Yes, if someone can come and do that for me. Sure. What is your threshold? That was a large pulsatile vessel. At what point would you think to switch to coag graspers instead of this method? If it's I think that's case by case. If I see it's really large, very large artery, sometimes I change it. Or if I use this and it doesn't work, for example, I still see the blood vessel behind it. I'm cutting it back now with sweet coag but I'm going to cut slower. Hopefully there's no bleeding. There's no bleeding. Good. Sorry for this the blood but we go along the plane. Close please. I will dissect a little bit more here and then I will retroflex and dissect from the mucosal incision and dissection from the retroflex position. Open please. Yes. Now I'm using sweet coagulation at 440 watts. When you were dealing with the large vessel, you switched to forced coag? Yes, forced 110. Sorry, 7 watts. He used 110 watts but that's different knife. This one is dual knife so we decrease it slightly. I think we now we cut until here so I'm going to start dissection in mucosal incision and dissection from the oral side. Can I have injection please? With O-Rise. O-Rise gel from Boston Scientific. I prefer this solution because it lift the lifting last long time but usually I will not inject it directly first time. I will inject it because there's already slight fluid underneath because I try to avoid inject gel into the muscle. And when you do a lot of rectal ESC you see muscle in the distal rectum it has a complex anatomy so what's described as window blind appearance many times you go in between the muscle fiber and you can go through you can dissect through the muscle fiber. So we have to be very careful not to not to inject into the muscle layer. So that you don't have in your experience there's no problems with mixing solutions? No problem? So she's counting the fluid amount and we always do that because if we if she inject 1cc and I don't see lift I know that I went through. Inject please? 0.5 1 sub Inject 0.5 1 1.5 I make two three dots here so I know just for when it come out this is the mark that inject indicate proximal margin 0.5 1.5 Sub Slight lift there. Inject So you see that I don't inject, I don't put the whole knife in. Usually that went through sub small amount, small length into the plane that's enough. You don't go in the whole knife in, usually you go to the muscle. Inject And then pull the knife back when you see lift Sub This is a beautiful demonstration of this sort of dynamic injection. I think we're going to switch over to back to Greg now at NYU and then we'll come back to you as you have a rest. Thank you. So as we discussed, we finished complete mucosal incision from the oral size and then we finished dissection in a forward reposition and that's what left here. Oh, wonderful. So I would like to show one thing. This is like when you move the scope for the beginner, try to have the scope past the wall like don't cut like this because it's not really stable. So I have the scope part of the tip past the wall. Open please. And then you can talk the scope with your right hand and you see the line mucosal line cut along that. This is not to do dissection but to separate the remaining mucosa, submucosa by talking and it will be a lot, somewhat faster than using the the the Okay, we're almost done here. And gravity is providing you with very nice traction. So I haven't changed patient position because this is a position we chose at the beginning and it worked well. So we finished. Wonderful. Beautiful. I'm going to remove. That was we did not see any muscle injury so you can see. I leave a little bit of submucosa. We don't have to cut very close to the muscle. This is I'm getting off the smoke so you can see here. So next thing is I will use a quack rasper to coagulate any blood vessel. We actually treat hemorrhoid a little bit before we continue because there was a slight oozing. So I'm coming back to the enorectal area and this is a slight hemorrhoid left. I will coagulate that. And will you plan to close this lesion at all? Usually I don't close the lesion at enorectal junction. I try to avoid the issue like we close and make it narrow and the patient have obstruction. The risk of can you take that please? The risk of stricture is very low. So our Japanese colleague reported the large regulation stricture is less than 5%. It's not like in the esophagus. And even if there is a stricture dilation one or two times usually that's enough. I usually don't close the defect in this area. Now I'm using a coagulator the 5mm one. And soft coagulation No, no. Go back. This is okay. That's fine. Do you prescribe any stool softener in the TST? Yes, yes. Only the lesion near the dentate line. I don't want the patient to be constipated. So first ask them to take if they are constipated, take myolex and stool softener. I give them pain medication when I discuss close with the patient in the clinic so they have it at home already. They need it, they have it ready, open to avoid them have to come to the emergency room. Close Open And how would you follow these patients up? When would you repeat If no cancer open I believe the update guideline from Japanese society. Close Follow up One to three years Last colonoscopy was food prep, no other polyps that first that they have to follow and this one we remove it on block then patient can open, follow up with the local gastroenterologist in maybe two years, one and a half, two years. But if you do this, you have to follow in six months. Six months and another time 18 months and treat and more frequently it come back. If it come back in this area, it's going to be quite difficult to treat. So I think we calculate all the hemorrhoids. Close So let's see again, a little bit more a little bit of those things There's one question Would you like to cauterize the margins to prevent recurrence? For large open for large EMR, yes now we should close we should try to do that because that has been shown to reduce risk of recurrence I don't know Would you still do it for ESD or you think it's not necessary if you've done it? I don't think we need that because we already cut, you see the margin and we cut about 3-5mm outside the margin even more reliable than calculation. Because you do soft calculation, you never know that you really treat all the residual that you don't see but this one you see that you already take it all out. I think we're done Wonderful That was really beautiful very well demonstrated

rectal polyp

colonoscopy

ESD

H190 endoscope

muscle injury

follow-up protocol