EMR on the ASGE SuTab tip of the week. This is a lateral spreading lesion in the rectum and it provides a useful opportunity to talk about this intersection between the use of the CAP technique to deal with fibrosis and the use of avulsion. So this is a lesion that has been worked on by more than one referring physician on four separate occasions before it was referred. I think as we've discussed that in general, the first attempt is unsuccessful in completing the apparent resection. It's probably best to send the patient to a referral center but this lesion is very fibrotic and we are starting off using the CAP technique because most of the area that the polyp originally occupied is still occupied by polyp that's regrown over the surface. So it's a pretty broad surface area. It's like too much to deal with with regard to avulsion. We would be picking at it for a long time. So we're starting with the CAP technique and it's actually, we're pulling the tissue up through the snare into the CAP and holding the suction for a long time. Sometimes in a really fibrotic lesion after the tech tells me that they've got a hold of the tissue, I'll hold the suction for just a few seconds longer to really try to get the snare to sink on to that tissue so that when we let go of it, we'll be able to see it. But as you're watching this, you'll see that we are in fact leaving some areas of the lesion intact. They are resistant to this CAP technique and so we're gonna have to come back and use avulsion for those. But the idea is that we'll be more efficient if we start off with the CAP technique to deal with the flat and fibrotic areas and then hopefully save small bits for avulsion because it doesn't remove as large a piece of tissue with each attempt or each pass of the avulsion forceps as we can achieve with the CAP technique. And these previously worked on lesions in our experience and this was recently shown in a paper in the Red Journal by the Australian group. Basically all of them can be dealt with by traditional EMR. Now we did inject this lesion and you can see that quite a bit of it looks blue in the submucosa. So that helps us to define that submucosal plane that we need to be resecting in but there also are some areas that are just marked by severe fibrosis. So you can see the areas of red, those are of residual polyp and there are quite a few of these areas left to remove by avulsion. We are gonna talk about avulsion in a very soon upcoming tip this is hot avulsion which is the method that I prefer to use. It involves grabbing that tissue and holding it quite tightly and then pulling away from the tissue to get some mechanical tension on it and before it tears off, we are then applying a low voltage cutting current to separate that tissue hopefully in the same plane that we have been snare resecting in and you can see all the fibrosis in the base of this lesion but I think it helps to demonstrate this again, this intersection between the use of the CAP technique and avulsion. We're finishing off with APC rather than snare tip to treat the margin. So to put the roles of the CAP technique and avulsion in perspective in our modern EMR paradigm, you'll remember that that paradigm is that we begin traditional EMR by injection and snare resection and if we can completely resect all of the visible lesion, then we go directly to margin treatment. If we can't completely resect it, then we are not allowed to ablate any flat or fibrotic tissue because it's associated with an increased chance of recurrence at follow-up. So we have to then go to avulsion. So in a sense, the CAP technique fits in somewhat of the same role as avulsion but it allows us to extend the process of snaring and the CAP technique would be the initial way to approach flat or fibrotic tissue, especially if the surface area is larger because it is more efficient than avulsion. We can take off larger pieces of flat and fibrotic tissue at one time. If the residual flat or fibrotic tissue is very small, it's going to be more efficient and actually more effective and easier to apply avulsion. And in general, avulsion will get tissue off that can resist the CAP technique, that extension of snaring that we get with the CAP technique. Only after we have completed all of that resection process do we then proceed to thermal treatment of the margin to destroy invisible residual tissue cells that could survive and regrow as a recurrence. Usually we would do that with snare tip on soft COAG. That is a less expensive option than APC but as I showed in the last example, APC also can be used. We don't yet have a direct comparison of the two techniques. I will admit that when the stakes are high, that is there have been recurrences and the patient is being referred for treatment, I still sometimes use APC along that scarred margin as I did in the last case. But in general, the tool of choice for treatment of the normal appearing margin in the EMR paradigm is snare tip on soft COAG. Next week, how to evulsion technique during EMR on the ASGE SueTab tip of the week.

CAP technique

avulsion

fibrotic lateral spreading lesion

rectum

injection and snare resection