Today, hot avulsion during EMR on the ASGE SUTAB tip of the week. Last week we introduced the use of hot avulsion and the technique of hot avulsion and this week we will demonstrate the principles that we showed last week in the removal of some flat areas that resisted snaring during routine hot EMR. Here's another example of hot avulsion at the end of a hot EMR. You can see the area in the right upper part here. We've got some bleeding. That's often a signal that we've transected in the wrong plane. If we leave the muscularis mucosa and some of the polyp intact, we're more likely to see some bleeding and so we're going to remove that area by avulsion. We've grasped it. We've got the top cup on some normal mucosa. The bottom cup is in the semi-cosa. Again, we can use this technique for residual polyp that is either in the base of the defect or at the margin, the edge of the defect. Step one is to grab it. Step two is to tent it back, to put mechanical tension on it. That mechanical tension helps the separation occur when we briefly tap the yellow pedal, the endocut I current, the low voltage cutting current. Endocut I, lower voltage than endocut Q. A little bit of tissue left in the base. You can see the pink line of tissue. We've grasped it. We've tented it. We tap. Just a brief tap and it comes right off. Now there's a little bit of red tissue on the edge. This actually may not be residual polyp, but again, we want to be careful that we get a complete resection so we are grasping it. Not a firm enough grasp the first attempt, so we re-grasp it, get it firmly, and now hold onto it firmly as we tent and then tap. And then finally, we're going to take one more piece on the right here, although I think the resection is basically complete at this point. Now in the initial next grab here, we don't get quite enough tissue and you can see we pull the forceps off cold. That'll be coming in just a second and so we always have to strike that balance between getting all the tissue, all of the target tissue, and getting too much tissue. We want to grasp the right amount of tissue. We've got a little bit of bleeding because we basically avulsed that cold, so we're going to get a hold of it again, but get a firmer grasp on it, a slightly deeper grasp, and then repeat the process of tenting and application of current. You'll notice on the right that a fold is going to appear in just a second. There's a fold on the left and as we apply the current, we're going to get a brief burn. We're trying to avoid that during hot avulsion by keeping the metal off the normal mucose, so we can't always do it. If it's brief, it'll be okay. Another example of hot avulsion at the end of a routine hot EMR. Most of this lesion has been removed by snaring on the right, a little bit of loose tissue that will wash off, and on the left, a flat area that resisted snaring, so we're going to finish up the resection by avulsion. Note how the hot forceps, the cups, overlap the target tissue, extending into the submucosal defect just a millimeter or two. Second, the tension, the mechanical stretching that will help the tissue separate when we apply the cautery. Then just a brief tap of the cautery on the low voltage, pure cutting current, endocut ion, the 141 setting, and we get a result that makes it hard to distinguish in the submucosal plane where the avulsed area was from the snared areas. This kind of material in the base of an EMR defect that looks white, you can't see any red or flesh-colored polyp tissue. I don't know if that is going to survive or not. I sometimes remove at least part of this, partly because of obsessive-compulsive sort of nature, just to make sure that we have the very lowest chance of recurrence, but I think it's hard to know if you actually need to remove this tissue. But the technique for doing it, if you do it, is basically the same. So sometimes when I see this kind of material, I will grab it. Notice again, over and over again, just the millimeter or two of overlap of the cups into the submucosa. We're not too deep, but we do have a firm grasp on all of the tissue. And then as we stretch, we just tap and we get very nice separation. You can see there's that submucosal plane. Next week, the use of hot avulsion and the management of fibrotic disease on the ASGE SUTAB tip of the week.

hot avulsion

EMR

endoscopic mucosal resection

bleeding

transection