Today, treatment of partly resected polyps on the ASGE SUTAB tip of the week. First there are a variety of ways to approach polyps that have been previously resected in part and by that I mean that the referring physician removed part of the lesion and then stopped so that you know that there is residual polyp but there's going to be fibrosis along the edge or edges where the polyp was partly resected. I'm going to focus on standard EMR for this and we'll use a lot of the principles that we've already discussed including cap and avulsion which are more likely to be necessary in these polyps because of the fibrosis and depending on the extent of the fibrosis. I will say that underwater has a lot to commend it. I think when the mucosa and the wall of the colon are relaxed underwater that there's a tendency for the snare to dig in better and catch the mucosa at the point of scarring better than occurs when the colon is filled with gas. Some experts feel that this is an indication for ESD. I'm not one of them. First, I think that semi-costal fibrosis is every bit as much of a problem for ESD as it is for EMR and so I would tend to again choose ESD based on location in the colon and morphology of the lesion rather than it was previously partly resected and there's a movement toward the use of the full thickness resection device and this is one way to approach it. I would say that for these lesions and FTRD sometimes depending on their size there can be limitations usually over 30 millimeters is more than the FTRD device can do without at least some previous or partial resection or some resection before you apply the device. Depending on the amount of fibrosis it can be hard to pull the lesion into the cap. Sometimes it's hard to get to. There's always a period of time when new devices tend to be used in a lot of instances where they may not be necessary. I've had a couple of cases now where patients were referred to me for EMR after somebody couldn't get to a recurrent polyp or a partly removed polyp with the FTRD device because of redundancy in the colon or a very bad sigmoid and from an EMR standpoint they were chip shots. I will just say that all of these are appropriate methods but I think standard EMR and underwater EMR have a lot to say for them because of their simplicity. They're much lower risk of perforation than both ESD and FTRD in this setting. Here's a flat adenoma in the cecum and you can see the scarring at the bottom of it where the referring physician removed part of it and then I think became concerned about the flatness and the location decided to refer it. Of course it would have been better if they had not started it but it's definitely something that should still be referred because these kind of issues are usually not too hard to deal with. Only maybe 10-15% of the circumference is scarred. A difference here between the treatment of a partly removed polyp and a recurrence is that there's a lot of it that's not scarred so we typically are going to try to lift it. We will do a standard EMR and then we're going to ablate the entire normal appearing edge. I tend to use APC in this setting or I have in the past. Again we don't have a comparative trial of APC versus STSC. I kind of like it because I think the stakes like the APC I think the stakes are a little bit higher to make sure that we've got good destruction of the area along the scar and then finally we will close this defect up. Here's another lesion that was partly removed. You can see the large scar above the lesion and this is not very big. Sometimes when you look at these you ask yourself what the problem is. You might be thinking that right now this is not a very large lesion but I think what you don't know is the difficulties that were encountered on the day that the referring physician was attempting it. There could have been a loop in the scope. There could have been some trouble with access but because it's been partly removed even when they're small and our experience is that on average these are smaller than lesions that are referred de novo. We tend to be fairly aggressive. We will remove the part that is not scarred down by EMR. Here we did an on block EMR of that fairly small area of residual disease and then we're burning up the perimeter with APC. You could also as I've mentioned several times use snare tip on soft COAG and then finally because there tends to be a greater amount of submucosal fibrosis and I do have some concerns about injury even when they're small I will close these defects with one or more clips to prevent delayed perforation. Here's another partly removed polyp and a very typical confirmation where the referring physician has removed the distal part of it. The part along the distal side of a haustral fold. You could see the scar there as well as the distortion of the fold. There's a V-shaped deformity of the folds that is created by that scar and the folds emanating from that scar. This approach which I'm suggesting to you is successful in the overwhelming majority of these cases is to do EMR on the part that is not scarred down and then basically burn up the edges and clip close this. My experience has been remarkably safe, it's very easy to apply, it's quick to apply and it is successful in really the same percentage of cases that we encounter that have not been previously worked on. I recommend it to you for its simplicity and safety. We do expect that we're going to have to use the CAP technique and or evulsion more often because of the fibrosis and you can get a sense of the fibrosis right along the scar on the distal edge of it. So we're trying to snare it, actually wanted to use the CAP technique but because of this V-shaped deformity in the folds emanating from the scar, I had a very hard time approaching it to do the CAP technique. There you can see that red area, that's cut in the wrong plane, that's residual polyp that has to be removed and I couldn't get at it with the CAP. So we are going to remove that in several pieces using evulsion and then when we're finished we'll burn up the edge. In this case with APC, we can use APC or STSC and then close the defect. Very safe and very effective approach to the partly removed polyp, there it is almost fully closed with clips. Next week, tips for resection of pedunculated lesions on the ASGE SuTab tip of the week. Visit www.SurgicalScience.com for more information

polyps

EMR

underwater EMR

FTRD

resection