on the ASGE SuTAP tip of the week. Continuing the discussion of resection of ICV lesions, we'll move to water floating and retroflexion, two techniques that can be valuable almost anywhere in the colon. But today, specifically, they're used to access ileocecal valve lesions. This is a lesion that's on the proximal lip of the ileocecal valve. And it's not very large. It looks like if you wanted to inject on the other side of it that it would be difficult to get the needle around to the other side because it's sort of sitting on that difficult to access part of the valve on the medial wall of the cecum. And clearly, we don't want, if we can, to inject on the anal side of the lesion because we're gonna push it down further even into that area. So we're gonna discuss the use of water floating here. Now, this is basically underwater EMR, the technique that Ken Benmoeller described. I'm calling it water floating here because I think one of the uses of this technique is basically to float lesions up and allow you to get access to them because they're sort of otherwise hidden. So you can do this anywhere in the colon, but I think one of the areas where it's most useful is for lesions that are on the proximal lip of the ileocecal valve and extending down into that space between the ileocecal valve and the appendiceal orifice, the medial wall of the cecum. So the technique I think everybody is familiar with, which is to suck the gas out of the colon and start to instill water. And when you do this with the ileocecal valve, one of the things you'll notice is that the valve will start to turn toward you. It will turn on fas to you. And you can see there's that appearance of the valve looking straight at us. And as that occurs, the lesion itself is becoming more and more accessible. And I think if we did not do this, one of the issues that we would have is our snare would tend to close and miss part of the lesion that is over that proximal or cecal side, cecal lip of the valve. We're not doing any injection here. We're basically doing this water floating thing. We're basically taking the gas out, filling the colon with water without any form of injection. And then we're gonna use electrocautery to remove this. We've got a relatively small snare. Now this is a fascinating case. This is something that I see a lot. The patient comes in and says that when this was found, now you can see how accessible that thing is. Basically just sticking up there like a sore thumb. So I call that water floating. This can be done in the sigmoid colon with pedunculated lesions. If they're lying away from you, just kind of float them up so that they're sticking straight up. And I said that this patient, when this lesion was discovered, she was actually referred to a surgeon. And then she said she didn't want to have surgery. She wanted to make an attempt at endoscopic resection. And so then she was sent down to us. And you just wonder how often patients actually go along with that recommendation. But here's a good example of a lesion that's probably only 12, 13, 14 millimeters in size. And it's off with a fairly simple maneuver. So it's a reminder that for benign lesions, we shouldn't send them to surgery. There's a little bit left here that again, we're gonna take off in this water floated position. So water floating or doing underwater resection, a tremendous way to access difficult to approach lesions on the valve. A final tool that should be mentioned for resection of lesions on the ileocecal valve is retroflexion. Retroflexion can be useful anywhere in the colon. The areas that I use it most often are in the ascending, especially the distal ascending, the hepatic flexure where oftentimes at least the injection, if not much of the resection is most easily performed in retroflexion. In this particular case, we've got a lesion that you see sort of rolled away from us. We were initially looking at it almost on FOS and then with increased distention, it just rolled away from us. And we're starting off using a tool that I think is easier to use for access, the one we showed previously, which is underwater resection. But you'll see in a minute, there was a portion of this on the proximal lip of the valve that I just could not access even with underwater. And so we went in to retroflexion. Now, general rules about scopes and what scopes to use. In the right colon, the transverse colon, I think it's fine to retroflex with a colonoscope, also in the rectum, of course. When you're in the sigmoid or the descending, probably best to use an upper scope because you don't wanna get caught in retroflexion. And anecdotally, that has happened to colonoscopists in the left colon above the rectum. And in unwinding the scope from retroflexion, perforations have occurred. So scope selection is important. In the cecum, scope selection is also important. Here, we're using an adult scope and we've got enough room to retroflexion, actually look at this part that's on this cecal lip of the ileocecal valve that I just could not access in the forward view, even underwater. And we can do this with a colonoscope, but it all depends on cecal anatomy. If you have a very short cecum, you may need to use a pediatric colonoscope. And occasionally you need even a scope with a very short bending section, such as an upper scope or an enteroscope because there just isn't enough room with a colonoscope, either adult or pediatric scope, to turn around and look at the valve. So retroflexion, I think, can be useful in any part of the colon, but some sections are anatomically, they're just the nature of it, it's more likely to be necessary. I don't think it's a really commonly used tool on the valve because other things are easier, but you need to have it in your armamentarium, your bag of tools for ICV lesions. To summarize tips for successful resection of ICV polyps, first use a cap or distal attachment on the end of the scope. Second, begin injection on the margin closest to the ICV orifice and begin resection there also. For identifying the margin of lesions, especially adenomas in that transitional zone, you may need a steady hand and a high definition scope. Expect semicostal fat exposure. The risk of perforation is very low, but bleeding can occur. Prevention of bleeding by clip closure is challenging because of the valve stiffness. And remember for access, water floating and retroflexion. Thanks and see you next week on the ASGE SuTab tip of the week.

water floating

retroflexion

ileocecal valve

underwater EMR

scope selection