Today, overcoming access issues underneath the ileocecal valve on the ASGE SuTab tip of the week. Let's look at a very difficult EMR and ask the question, how would you solve this challenge? So this lesion is a challenge for EMR and the question is how would you solve this? How would I solve it? This is a benign lesion, an adenoma growing on the cecal side lip of the ileocecal valve and as we've discussed, we don't want to send benign lesions to surgery but as you can see we're going to get stuck in the process of resection. We began the EMR by injecting on the side closest to the ileocecal valve orifice which the value of that of course is to push the lesion away from the valve orifice so we don't shove it down into the ileum. The problem with this sometimes on the side that is toward the cecum is that we push the lesion into the cecum. So you can see a bit of scarring off to the left there from where the referring doctor took a few biopsies and you can see there's a really substantial amount of tissue. This is a non-granular flat elevated lesion. There isn't any aspect of it that looks to be high risk for cancer so very benign. We did go down to the most anatomically proximal part, the cecal most aspect of the lesion to inject it and now using a small snare we're going to try to get the lesion up into the snare. We're going to use a bit of cap technique from time to time but in general we're sort of piecemealing this thing. As I've mentioned before, any time that you have got lesion disappearing over a haustral fold, disappearing over a flexure and you're sort of chipping away at it from the proximal aspect, then you really should not underestimate how much more polyp can be on the other side and you need to try to figure out a way to get a better look at it. We're doing some of this from the anatomic distal side, we're sort of piecemealing it but the whole time I'm concerned that there's really quite a bit of lesion on the other side. We've got the cap on an adult colonoscope here, we're washing now, you can see some exposure of submucosal fat off to the right. We're sort of trying to turn the valve more toward the right, seeing if we can get underneath it with the scope but the concern here is that we've got a lot of benign adenoma that we need to access for resection. How are we going to accomplish this and complete this EMR? How do we solve this challenge? Going underwater is a good thought. We showed in a previous video tip with a semi-pedunculated lesion on the secal lip of the ileocecal valve how it floated a lesion up and created good access. In this particular case with a flat, non-granular lesion, it was tried, it didn't provide enough access. The valve is very stiff and sometimes lesions don't float up well off the valve. So it looks like we are going to need to go into retroflexion. We definitely want to get the cap off. Is getting the cap off this scope and using it enough? I didn't feel that it would be. The turning radius of an adult colonoscope is large and this particular cecum has a very small size to it. We need something that's going to turn in a very small area and still allow us to stay far enough away from the lesion that we can see it well. Here are three colonoscopes. The adult standard colonoscope, the pediatric colonoscope, and the ultra-thin colonoscope. This is what we're currently have been using so far in the procedure. So we could switch to one of the thinner instruments, maybe have a little bit tighter turning radius. I probably would choose the ultra-thin, but we are in a very narrow space in the cecum and we're going to have an advantage if we switch to an even shorter bending section that has a tighter turning radius. So for that, we need an enteroscope or an upper scope rather than one of these instruments. Here are options with regard to upper endoscopes. Here's a standard upper endoscope and here is the SIF 180 push enteroscope. They both have shorter bending sections, a very tight turning radius. In the left colon, the sigmoid or the descending, clearly the upper endoscope is the preferred choice because of the shorter working length. In the cecum, I think it depends on how redundant the colon is. When you're in there with the colonoscope, if you have a nice short scope, you're probably going to be able to get in there with the upper endoscope. The advantages of it are that the instruments are much easier to use. With the enteroscope, sometimes it's quite difficult to get the instruments to come out the tip, especially when you're in retroflexion, you have to unwind each time you want to change instruments or sometimes even each time you're using your snare. You have to unwind, push the instrument up to the tip of the scope, and then go back into retroflexion. In this particular case, the colon appeared to be reasonably short, it had about 75 centimeters of colonoscope in, in order to get to the cecum, so I chose to go back in with the upper endoscope. Picking up where we left off before with this lesion, here are the final views with the colonoscope, the cap on the tip of the scope. We're turning sideways, trying to see if retroflexion is conceivable, but it's a fairly short cecum, there isn't a lot of space there, you can see that residual polyp on the cecal surface of the valve. So we switched scopes for an upper scope, you can see the instrument now coming out at eight o'clock, and when you talk to the technician to get the upper scope for you, you want to remind them to get the one that has the best tip deflection. Upper scopes normally have 210 degrees of deflection in the up direction, and when they are maxed up and maxed right or left, they really should have a very nice hairpin shape to them, and you need that to be able to see well and to access the lesion. We're doing the pivot maneuver here and trying to complete snaring. We don't have a cap on the scope, if you were very close to the lesion, the cap would seem like sort of a nuisance, and in terms of the cap technique, you really can only do that with an adult colonoscope. Even for a pediatric colonoscope, the surface area of the cap opening is just not enough to really draw tissue up into it well, so we're up there without a cap on, so we're going to have to resort to standard snaring and or avulsion. And we're using a 15 millimeter snare, you're going to see it slip off, so we switched to a 20 millimeter snare to sort of get it over the entire sacral side lip of the ileo-sacral valve and get a hold, we got a hold of a decent piece of tissue on the valve now, but in fact, snaring was very difficult, even when we're looking on FOS at the lesion, you'll notice that really in the forward view, we probably had resected less than half of this lesion. We're now cleaning up a couple of areas using hot avulsion. But I think the key here is that this lesion, which turned out to be a tubular adenoma with low grade dysplasia, is a challenge for EMR and we need a solution for it. And the point here is that choosing the right scope was the solution, we needed an instrument with a tight bending radius that would allow us to turn around, see the lesion on FOS in a relatively short cecum, because with a colonoscope, we had a fairly straight scope, it's not a long redundant colon, an upper scope would work, it's a lot easier with an upper scope than with an enteroscope. And in the left colon, in the descending or the sigmoid, an upper scope will almost always do go up proximal to the lesion, if you have a difficulty accessing part that's over a haustral fold retroflex, and then you'll be able to look at it on FOS. So this lesion needs STSC and clipping, but the key thing is that we've saved this patient from an operation for a benign colorectal lesion. Thanks and see you next week on the ASGE SuTab tip of the week.

benign lesion

ileocecal valve

endoscopic mucosal resection

upper endoscope

scope selection