This is another lesion that we saw last week when we were talking about differentiation of residual adenoma from a CLIP artifact and this was the interesting case in which the referring doctor had apparently removed the entire polyp but wanted me to do the follow up and we're seeing the lesion fairly early at about two months after the initial resection. And you can see there's some CLIP artifact. I tried actually to lift this, I injected on the proximal side of it and as expected it did not lift well. I felt that the residual areas, there's one area at the left edge of the scar and two right next to each other at the right edge of the scar that they were so flat, there was so much fibrosis that snaring was unlikely to be successful so I went directly to avulsion. And although we don't really have tissue underneath the, we don't have fluid underneath the tissue that we're grasping, avulsion is still I think very safe. We're using the endocut I141 setting but we want to get this tissue off with resection rather than ablation. If we just use APC and burn it up, we're guessing and we're guessing whether or not we've got the injury deep enough to destroy the tissue. You can see at the right edge now that we've already got a very nice submucosal defect where we've done some avulsion and now we're just continuing that process. We grab a hold of the tissue and we are tenting the tissue and then we're going to tap the yellow petal repeatedly. You can see with each tap it separates a little bit more and the separation is very nicely in the submucosal space so we can be confident that we're really resecting this residual or recurrent tissue and the technique for this avulsion is exactly the same as the technique that we described for EMR earlier. We grasp the tissue, we lift it up and then we tap the yellow petal on the endocut I141 setting. Now you can see both sides of the scar where the recurrences were very nicely taken down to the submucosa. We chose to use APC and then to burn up the edges again, not to ablate tissue but to burn up the edges and then clip. Here's a lesion I didn't show last week. This is a large lesion removed from the dentate line and I was actually biopsying this, taking cold biopsies of it when I realized that there was residual polyps so I was thinking that there wasn't any and then all of a sudden I saw it there. You can see it in NBI, the typical nice two pip pattern and good delineation of the margins. Very flat. I did try to snare it and I didn't succeed so we're going to go with avulsion. We're going to get a firm grip on that tissue. We want to keep the metal off the squamous mucosa to the extent that we can so that we don't get a burn on the squamous mucosa where the patient may feel tenderness and discomfort and so we're removing a very nice separation in the submucosal plane. Again we're using endocut I on the 141 setting and once we get some mechanical tension we are just tapping that yellow pedal trying to make sure that none of the metal on the forceps is touching any of the adjacent tissues so things I think are going quite well here. Now we're at the dentate line so we're not going to clip when we are finished rather what we'll do is burn around the edges again we'll have the option of either STSC or of using the argon plasma coagulator and as you'll see in a minute I did decide to use APC to go around the margin again we have got the last bit of polyp tissue or even potential polyp tissue and we've tinted it and then tapped the yellow pedal so successful avulsion either snaring or avulsion is the first step and then thermal injury to the margin of the defect is the second step and in this case there won't be any clipping and this is and was a very successful treatment of this recurrence after EMR of a large rectal lesion at the dentate line. Here's a scar off to the left that's recurrent polyp somewhat polyploid recurrence on the far end of the scar you could see some clip artifact some mature clip artifact this was really polyploid down in the angle between the cecum and the ileocecal valve so difficult the snare had to go at it two or three times with the snare to get it looking like it was all out of there but it's looking pretty good at this point again if there was any residual polyp that I couldn't snare I would go to avulsion once the polyp is completely treated then we are going to go to margin treatment that normal appearing margin we're going to treat thermally in this case with APC again we could use STSC we don't have any kind of controlled trial of the importance of this for treating recurrences but I think it's smart as we've talked about before STSC as well as an earlier study by APC showed that both were effective in preventing recurrences when they're used to treat the normal pairing margin after EMR but we want to treat the entire margin we're bending the the defect down really well to get around the entire circumference of the margin and then it's a bit of a difficult angle but we'll try to close the defect not so worried about the area that's treated with APC but the central area that we removed by snaring in particular we're going to try to get a couple of clips on and this appears to be a good treatment recurrence of recurrent adenoma at the ICV this is an SSL recurrence it's another of the lesions that I showed last week this lesion was originally removed by cold EMR which is why that scar is so nice and smooth and we have the two little dots of recurrence up at one edge now even though the lesion was initially removed by cold EMR my preference is to use electrocautery to treat the recurrences I think it's more reliable it has been more reliable in my experience there's less bouncing of equipment off the underlying scar but we don't know for sure from a randomized control trial that it's necessary some would use the cast technique but I'm applying all the same tools that we've discussed that is snare or evolves then burn up the edges and then clip close for this SSL recurrence this is an interesting lesion that I saw recently also somewhat alarming this is about six weeks after an initial resection that's actually a small nodule of clip artifact at one end this lesion was removed by cold EMR by the referring physician had a clip placed at one end of course we are hoping to not use clips after cold EMR but as you're looking at this in MBI you'll see that the entire perimeter of the lesion is residual or recurrent adenoma this is the largest residual adenoma after cold EMR that I have seen it basically occupies the entire surface of the scarred or treated area so we're going to treat it like a recurrence using the principles we have discussed we are going to resect all of the visible lesion and then burn up the margin and then close it and actually tried to lift this lesion and it did lift and I think that this suggests that it was not cut during the cold EMR in the right plane in the submicosal plane it's a reminder to all of us that when we're doing cold EMR we make we need to make sure that we're cutting through the submicosal we know from several studies that we're not going to be cutting as deeply as we do with hot EMR and we expect in the randomized trials that are ongoing that I've alluded to a couple of times that the recurrence rate is going to be higher with cold EMR but we think it's going to be acceptable and that the recurrences are still going to be relatively small and easy to treat at follow-up so this is a relatively large recurrence that I think again is interesting and some somewhat alarming and there's a little bit of tissue not cut in the right plane so we're going to have that's in the middle of the defect now we've got all that taken care of and we're going to burn up the margin with the snare tip on soft coag burning up the normal margin and then close it so again treatment of recurrence resect all the visible lesion then burn up the margin and then finally close the defect to give you a sense of how this is going in my own practice this is our experience published earlier this year in gastro 2411 non-pedunculated lesions 20 millimeters or larger removed by EMR with a median interval the first follow-up of six months the recurrence rate at first follow-up those that came to our center was 15.2 percent now that's very typical in the literature anywhere from a little bit below that up to over 20 percent of those about 75 percent 201 of them were overt so they were treated another 65 were seen only on biopsy now clearly those weren't treated of those that were overt and then undergo treatment and follow up the eradication rate from the initial treatment was 87 so it's very high but it's not perfect in my opinion generally at a center of experience in EMR you should stick with it because you will eradicate it almost invariably but the patient and the physician both need to stick with it if you look at the histologic only recurrences and again remember for both overt and histologic only we going to wait another year before we do the follow-up 27 percent developed an overt recurrence so actually 75 of them never develop an overt recurrence i think you pull literally pull the cells off that have residual tissue by taking cold biopsies of the scar but that rate of overt recurrence is higher than the rate of subsequent overt recurrence in those who have neither overt or histologic only recurrence at first follow-up and you can see that in the bottom bullet the median follow-up between the first and second interval 13 months again so we're waiting a year before we do the second follow-up and if you take the group who have no first recurrence either overt or histologic at the second follow-up at our center 2.7 percent of them have an overt recurrence then we're going to treat them again with the methods that we've discussed but that rate is much lower than the group that has a histologic only recurrence and i think that is a potential value of biopsy as a marker of subsequent overt recurrence next week treatment of partly resected polyps on the ASGE SUTAB tip of the week

lesion recurrence

cold EMR

endoscopic mucosal resection

avulsion

thermal treatment