EMR on the ASCE SuTab tip of the week. This is a flat, elevated, non-granular lateral spreading tumor. And when you look at this thing, the thing that strikes you about it is its flatness. It's extremely flat. And it tended to resist sneering when we started. And so we are removing, essentially, the entire thing using the CAP technique. Now, I start almost every referred EMR with the CAP on. And many times, I don't use it at all. Sometimes, I'll use it for one piece of tissue. Other times, we resect almost the entire lesion using the CAP technique. And this is a good example where we're using it to deal with just the flatness of the lesion. So you can see the basic technique again. We place the snare over the tissue, approach it very closely, then suction the tissue up through the snare, and then close the snare, and then release the suction. And then you can see that this becomes a way pretty quickly, actually, to move across a fairly broad area simply to deal with the flatness of the lesion. This is a granular LST in the left colon. Notice right now, the CAP is not on. This is an interesting colon. The patient was referred really for two reasons. One is this lesion was discovered in the left colon. It's actually about 70 millimeters in length. It's really quite a large lesion. You can only see part of it right now. The other one was that the colon was actually redundant and dilated, unusual for ulcerative colitis. So I first went in without the CAP on to complete the colonoscopy. Then came back, did the injection, tried to snare it, and had a very difficult time getting a hold of any of the lesions. So I took the scope out, put the CAP on, and have come back up, and am now using the CAP technique really to resect the entire lesion. Now, the injection fluid, although it's not really lifting the lesion extremely well, it still helps to identify that submucosal plane and to verify for us that we are in the correct plane as we go across the lesion. So I still, typically, when we're dealing with a lesion that's been previously resected or that is naturally fibrotic, like this lesion in ulcerative colitis, it's still great to inject with a contrast agent so we can keep track of the correct plane, keep moving across the lesion with the correct plane. Once again, you're seeing over and over again the use of the CAP technique, place the snare over the target tissue, then approach that tissue closely, use suction to pull the tissue up through the snare into the CAP, the snare is then closed blindly. When the tech tells you they feel it, you release the suction, and then perform the transection using electrocautery. So again, this is kind of an unusual case, different than the usual scenario. The most common scenario is I don't use the CAP at all. Or when we do use it, typically it's only for a small region of the lesion. But this shows you the potential utility of the CAP in certain instances of extreme flatness, like we saw in the last video, or in this case, a lot of submucosal fibrosis, utility to resect an entire lesion by EMR with the CAP technique. Here's another non-granular, flat, elevated, lateral spreading lesion, no pseudodepression, so very low risk of cancer, good candidate for EMR in the traditional inject and resect method. We typically start off doing resection without using the CAP unless we need it, as we did with the previous lesion. But I like to have a CAP there in case we encounter one of those flat areas. We already talked about how this CAP can be very useful also for access on the ileocecal valve, on the medial wall of the cecum when there's tissue extending over a fold. And so most of this lesion is being removed by simple resection and without the use of the CAP. But here in the very last piece, we're gonna put it to use. This is an area that was hard to access. The snare was sort of cramped when we stuck it over that fold. So we're just going to put the snare over this tissue, approach it closely, suction the tissue up through the snare into the CAP, and now the technician is closing them. We're just gonna wait till they tell us that they can feel the tissue, then we'll release the suction and inspect the tissue carefully and then resect this. So this is a very common scenario where for one or two key areas that are flat or more easily gotten a hold up with the CAP, we put the CAP to use. Here's a granular lateral spreading lesion in the proximal ascending colon. This actually extends up onto the ileocecal valve. It has some lack of uniformity. The area on the left is a slightly lighter color and more granular than the area on the right, which actually is sort of non-granular. It has a mixed pattern to it. We're starting off our traditional inject and resect EMR. We're not needing the CAP, and then we're going to encounter a region, you can see it here, where there is a greater amount of submucosal fibrosis, and I think this is not at all an uncommon situation with lateral spreading lesions is that there is a particular region in the lesion that tends to have a greater amount of submucosal fibrosis, and this is where the use of the CAP is more likely to come into play. So we are using now a small snare. We are gonna either use the 10 to 15 millimeter stiff snare or that 11 millimeter flexible snare, or if you're using snares from another company, something in that size range, and you've seen now multiple times how we are doing the same technique basically over and over again with the CAP, which is to place the snare over the target tissue and then approach closely and suction the tissue up through the snare and into the CAP. Then there's that blind part that is really important that the tech is able to close and feel the tissue, report to you that they've got it, and then you release the suction and take a look at it. I will show in a later tip the use of this technique with out electrocautery by Cold EMR, and as I've mentioned, you don't necessarily have to release the tissue. My own preference is to release it if you're using electrocautery and take a look at it, but really the CAP, as you can see, is very nicely allowing us to stay in that correct submucosal plane. There you can see quite a bit of fibrosis, and we're gonna just continue to move across this with the CAP technique. We've got the left side of the snare next to the lesion. We're suctioning, and we're dealing here with significant amount of sort of regional fibrosis, really over two to three centimeters of this lesion, and the CAP technique is, for me, the trick of this. If we were trying to avulse to cover this area, the size of a region, it would really take us a long time, but actually we can do it quite efficiently using this CAP technique. The safety, again, is that the device is only sticking out three to four millimeters from the end of the colonoscope. This is not like the sort of banding CAPs that we use for EMR in the esophagus. It's much more shallow than that, and that's where the safety lies, and this is a very typical way that the CAP technique is used in EMR. To summarize, we've talked about just a few of the uses of this soft, flexible CAP on the tip of the colonoscope for resection. First, the exposure of lesions on the ileocecal valve, the medial wall of the cecum, on the proximal sides of folds, and secondly, during EMR for the removal of flat or fibrotic tissue that resists traditional snaring approaches. This is a complementary tool to avulsion. Avulsion, I think, is more appropriate for tiny areas of flat or fibrotic tissue, and avulsion is tougher than CAP. Avulsion will work when CAP fails, but CAP is more efficient when the area of fibrotic or flat tissue is broader. You can remove it faster with the CAP technique. If the CAP technique works, it'll save you time as opposed to avulsion, and you can save avulsion for the tiny bits of tissue that resist removal with the CAP technique. Next week, the interaction between CAP technique and avulsion on the ASGE Suit Tab, tip of the week.

CAP technique

endoscopic mucosal resection

EMR procedures

snare

avulsion