Today, management of lateral spreading tumors before referral for endoscopic resection on the ASGE SUTAB tip of the week. These comments refer to how to manage lesions that you encounter during screening or surveillance colonoscopy that you're not going to remove. Perhaps you're going to refer them to another center or to the endoscopist in your group that specializes in endoscopic resection in the colon, or perhaps you're actually going to remove it later yourself. You don't want to do it at this time because the lesion is so large that you think it elevates the risk beyond what you discussed with the patient as far as a routine colonoscopy or you don't have the time. It's going to set you far behind in the schedule, or you need to schedule it at the hospital. These are all sometimes legitimate reasons to do it at a later date. These comments refer to how to manage it at the time. So first of all, with regard to tattoos, if the lesion's in the cecum or on the ileocecal valve, I would even say that if you can photograph the ileocecal valve and the lesion at the same time, there's no need to tattoo it at all. The appendiceal orifice or the ileocecal valve can serve as excellent reference markers for you to describe where the lesion is. Don't tattoo under the lesion. We say to tattoo at least three centimeters away. Remember that the bleb that you make is going to spread out. If you put a lot of volume in, it's going to spread a substantial distance. So especially with the newer, denser tattoos, you often can confine yourself to the recommended volume, but put it a few centimeters away. And then finally, note the position of the tattoo in relationship to the lesion. I place the tattoo three centimeters distal or three centimeters proximal or on the wall opposite the lesion. This will help later during endoscopic localization of the lesion. So what's the problem with having tattoo material under the lesion? In case reports of EMR, it's been associated with perforation, apparently by inducing fibrosis and making the layers stick together. In my experience, the biggest problem is when the needle appears to have been stuck straight through or under the lesion. I think that the needle injection itself can induce fibrosis. If the injection has been made several centimeters away and the material has spread laterally to get underneath the lesion, I've seen for EMR, little problem with fibrosis in that instance. When I talk to people who do ESD, they very commonly will say that tattoo material under the lesion is associated with more fibrosis. We don't know if one product tends to cause more fibrosis than another. For right now, bottom line is that we should keep tattoo material away from the lesion. Don't let it get under the lesion. Here's an SSL where the referring physician has placed a tattoo off to the right and it's spread through the semicostal under the right half of the lesion. This is what we're trying to avoid because it could potentially cause semicostal fibrosis. I mentioned in earlier tips that my own approach to SSLs to remove almost all of them using cold EMR. If there's semicostal fibrosis, this could be difficult. In general, I think that a lot of fibrosis is a contraindication to cold EMR because the snare tends to bounce off the fibrotic areas when you're doing cold EMR. You can see we're doing it very successfully here. This is my own experience that if the injection was made off to the side and the tattoo then spreads under the lesion, there usually isn't a lot of fibrosis, at least from the perspective of EMR. You can see the base of the defect looks black rather than blue. That's from the color of the tattoo, but we're trying to, in general, to discourage letting the tattoo get under the lesion. Here's an adenoma and LST on the ileocecal valve and the referring physician has tattooed this. It doesn't need a tattoo because the ileocecal valve has its own anatomic landmark and second, it's entirely underneath the lesion. That's what we're trying to avoid, again, in general because of the risk of semicostal fibrosis. In this case, we proceeded with EMR. No significant problem with semicostal fibrosis. You can see that intense black color of the semicosta as we begin the STSC process. In general, again, this has been my experience. If you make the injection outside of the lesion, it spreads underneath it, at least for EMR, usually not a problem with semicostal fibrosis, but we want to avoid this. A more important issue in the creation of semicostal fibrosis during the pre-referral management in my experience is the use of biopsy compared to tattoo. This is more likely to create semicostal fibrosis. Any flat lesion that is biopsied, you'll typically get into the semicostal. That means don't biopsy serrated lesions at all. We discussed that in a previous video tip, but it's also true for adenomas. Don't biopsy the flat parts. If you feel compelled to biopsy a portion of the lesion, biopsy the more elevated nodular parts of the lesion. Oftentimes people think it's okay to biopsy the very edge, thinking that that won't create much of a problem, but actually when you biopsy the edge, almost by definition, you're going to get into the semicostal. That's also not a good location. In general, unless you see evidence of cancer, and we'll discuss how to recognize that endoscopically in a later tip, there's really no need for biopsy before referral. The arrows here are on a line of white semicostal fibrosis underneath an SSL that we were performing cold EMR on. The cold snare just tends to bounce off these fibrotic areas. This was produced simply by biopsy of the center of the serrated lesion. You'll consistently see some level of fibrosis when serrated lesions are biopsied, and frequently when very flat adenomas are biopsied, that there's no evidence of cancer. There's just no need for biopsy, especially flat areas or the edge of the lesion. I want to emphasize here that this kind of problem created by semicostal fibrosis can invariably be dealt with at the referral center using a variety of tools. This is the CAST technique, cold avulsion snare tip technique that we're starting, and in later tips, I'm going to demonstrate how I like to manage fibrotic disease created by attempts at previous resection, but the point is that the job at the referral center is easier if we avoid creation of this type of semicostal fibrosis. Finally, the factor that is most likely to result in recognizable scar tissue and semicostal fibrosis is a previous attempt at resection that was incomplete, a partial resection. It's also very common. In our experience, more than 20% of all the lesions referred to us have had one or more attempts at previous resection. If you see a lesion that's very daunting from the perspectives of size or access or extreme flatness, then consider referral without any attempt at resection. If you do, and everybody understands this is going to happen, start a resection and then realize that it's too challenging to complete, stop at that point and still refer it on to the endoscopic resection rather than surgical resection because at the referral center they can still manage these issues of semicostal fibrosis. A good rule to follow is never biopsy a benign lesion with a snare or hot forceps. And finally, if you don't get it out in the first attempt, refer it then rather than make a second or third attempt yourself. To give a sense of how this looks at the referral center, here are some examples. This is a lesion in the ascending colon and the distal side, the anal side of this lesion has been resected. There's a scar along that distal edge. This is probably the most common pattern that I see that the distal part, sometimes it's the part on the anal or distal side of a fold that's been resected. Here's the same lesion with arrows delineating the scar on the distal side of the lesion from previous partial resection. There's a flat adenoma just to the right of the ileocecal valve. The red lines are around the adenoma. Right in the middle of it, there is a scar marked by the yellow arrows. I think in this case, probably it's the flatness of the lesion that created difficulty. Here's an adenoma to the left of the ileocecal valve. That's really sort of a mess after snare biopsies in multiple locations. Here's a photo of this same lesion. You can see the folds converging down towards scars. The scars are pointed out by the arrows, the kind of fold converging down toward areas of scarring and semicostal fibrosis created by previous partial resection. That's very commonly seen. There's a similar area off to the left that's out of view. This is actually snare biopsy in multiple locations. This is going to interfere with lifting of the lesion and it's going to make the resection more difficult and make it longer. I don't see this kind of thing very often. Usually, I'll call the referring physician and talk to them about the problems associated with this approach. Finally, here's a rectal adenoma that was worked on four separate times before I saw it. Actually, the entire area is still covered with adenoma. We're going to get it out with a combination of the CAP technique and the EVOLSION, the two techniques that I like to use to deal with fibrotic disease and we'll discuss in subsequent tips, but you'll see the entire base of this lesion is fibrotic as a result of previous treatment. I think it serves as a good reminder that if the first attempt at resection is unsuccessful, it may be best to refer the lesion. Finally, while we want to minimize these steps that can create semicostal fibrosis, when they do occur, don't refer the patient to surgery. Remember that surgery is associated with greater morbidity, mortality, and cost than endoscopic resection. Do refer the patient to your local or regional expert resectionist. Next week, choosing electrocautery settings for polypectomy and EMR on the ASGE SuTab tip of the week.

managing lateral spreading tumors

screening colonoscopy

surveillance colonoscopy

tattooing lesions

fibrosis