So let's think about this lesion. And first of all, let's just characterize this quickly. You can't see the whole thing. You can see maybe a quarter of it right here. So for those of you who are listening in, first of all, is this a granular or non-granular lesion? Granular. It's granular, of course. And I can tell you, it looks like this across the entire surface. There are lots of these little bumps, but there are no big nodules. So we would call this, most of us would call this a homogeneous granular LST. It's got a very low risk of cancer. And so piecemeal resection is a consideration. So I think the next consideration would be, is it okay to do this cold, or is it something that we should remove with electrocautery? And I'm going to admit that part of my thinking at this stage is asking myself whether or not I'm going to be able to close this thing. And this is a, you can only see part of it here, but it's about four or five times bigger than what you could see. And my judgment was going to be that this was going to be very difficult to close. Now, this is before X-TAC. Maybe you could close it with X-TAC. But what would you guys do? And is, I mean, do you think it's acceptable? Because what we're saying here is if we remove this with electrocautery and we don't close it, and it's four or five times this, this is in the mid-right colon, what is the risk of delayed hemorrhage, would you say? If we take it out with electrocautery. And don't clip it? Yeah, we can't, it's too big to close. We can't get it closed. I would say more than 20%, if not more. Tanya, do you think that's fair? I mean, I think that's fair. Yeah, I think there's, I mean, it's in the right colon. It's large. I think it has a high risk, independent of patient comorbidities that could influence it. But so yes, I think this is a higher risk lesion for that high rates of bleeding. Okay, it's also an adenoma, obviously. So what we're giving up by if we go cold is a higher recurrence rate. So one thing that I'm thinking about in talking, in thinking about with this patient is literally, am I sure this patient is gonna come back? I'm serious, I actually will. Like, you know, I evaluate that in my mind. Is this person engaged? You know, we use that word engaged. Like, are they involved in their healthcare and their healthcare decision-making? And you know, we all, I think, assess that. And if I would assess that this patient is engaged and there's a very high likelihood that they're gonna come back, then I'm less worried about a recurrence than I am that somebody got drug in there by their spouse and, you know, has had their first colonoscopy when they were 73 and, you know, has a lot of bad health habits, et cetera. You know, I'm more worried about this because I'm just more afraid they may not come back. But the trade-off here is if we go cold, we got a higher recurrence rate, but we go from this 20 plus percent risk of a delayed bleed to, in my mind, it's close to zero, it's less than 1%. And so in this particular case, I decided to go cold. So we've already talked about, you know, how to do this. And I'm not saying that this is a fast method. And when we talk about recurrences, you know, we're typically talking about, you know, recurrences that are very small. So we're, you know, we're taking off pieces here. You notice again, that push. You see how the tissue is popping up through the snare? Again, this is a 10 millimeter dedicated snare. And, you know, we're injecting here. I'll move down toward the end of this so you can see the size of this defect. But you know, it's probably about 50% of the circumference. And so it's a really, it's a really big thing. So now here it is six months later. So this is the ileocecal valve. This lesion was just above the ileocecal valve. And this is the scar and that is the recurrence. Now the recurrence rate, if you look at Cyrus Paraka's data, and Tom was quoting this, the recurrence rate here is the lesion is big, probably in the range of 75%. But we have gotten this lesion out with essentially a risk-free method. And now we're gonna take care of the recurrence using electrocautery, but this is almost risk-free because it's so small. And we, you know, we were talking about this, I just take these out with a hot snare, not lifting them unless they're sticking way out from the scar. And now some people would say that by definition, there's a type two muscle injury or you would treat it that way because the layers are kind of stuck together and you just, you know, aggressively used electrocautery to destroy this recurrence. But now we've clipped this closed, which I think essentially eliminates the risk of a complication. So we've sort of got through this entire resection without risk. And that's, so the part of the, I'm actually more likely to do a cold resection on a granular lesion that's so big that I can't close it than I am on one that's three, four, five centimeters in size that I think I can close. I don't know if that's crazy, but that's the logic that I would sort of invoke here. I think the only downside, I mean, not even a downside, definitely doing these large lesions with a cold snare takes more time because, I mean, you're not removing big chunks of tissue, but, and that is the reason why these have to be planned accordingly. You have to have ample time on the schedule, not to be rushed and, but otherwise it's a win-win. You have less risk of bleeding, less risk of thermal injury, as well as very, I mean, the recurrence is very easy to treat. I do think, though, we shouldn't say that that lesion couldn't be closed. I just, just to have, I mean, I think I hear all of your points, Doug, to minimize the post, the delayed bleeding risk in every way, but I think there are, as you said, there are potential methods available where we could close it, and so I think that's a consideration, too, to- I think even if you close it, the studies have shown that closure versus no closure still with cold wins out in terms of bleeding, right? I mean, that's the thing. Yeah. Yeah, but it, yes, I'm not saying that cold, hot has lower bleeding rates than cold at all. I'm just talking about weighing everything in the case of the resection, the recurrence and coming back, like we said, the, so that's all. Yeah, the key is to employ proper technique in the cold. If you do not a good enough job with the cold EMR and you have large area of recurrence, then it's counterproductive. Yeah, and I think if you have a lesion that's, you know, like 80% circumferential and you take it out cold, you have a recurrence in a stricture, that's hard to deal with. Yeah. So a variety of things come into play. I think it's good for the audience to hear our biases because I have a bias to sometimes use cold. I'm very comfortable taking out things with electrocautery. I sort of sense, I've always sensed with Tanya that she's kind of biased toward electrocautery. We don't have Cyrus Paraka here. Cyrus Paraka, when I hear him talk, and Cyrus is a good friend, he'll say basically my approach is either cold EMR or ESD. There's nothing in there, which is kind of funny. Yeah, yeah. Well, I think I hear for you here, I guess I think in these cases we're individualizing the risk in a way, right? Like it feels like there's not an all or none answer for any of these and that's where it becomes tricky. And I think that's something that we should at least raise is that when you're in a small community and you're doing this, you're gonna have a tendency to probably lean a little bit toward the side of something that has less risk of complication. Because a complication, I still think in a community, a small community is not as well understood. It's a little bit of protection from being in a tertiary center. It's kind of like my doctor thought this thing was so difficult or so important that I had to send it to you. So if something goes wrong, wow, it was a big deal. Whereas in the first run in a small community hospital, the patient may not have that sense. I also think, Doug, it goes back to one of the sessions about lesion assessment. I mean, like we can't take that for granted. It has to play into our decision-making. Like in this case, you looked everywhere, it was homogeneous, you'd see it's an adenoma only. I just, I think that that's something that can never be underscored enough. Right. Thank you.

granular lesion

colon

cold resection

recurrence rates

endoscopic resections