This week EMR lesions at the anorectal junction on the ASGE SUTAB tip of the week. So here is a granular lateral spreading lesion and adenoma at the dentate line. It's a homogeneous granular LST so it has low risk of cancer but of course we first inspect it to make sure that there are no nice three changes. Also it's homogeneous in the rectum I think when there is a large nodule especially if it has any different color to it, if it's sort of firm in appearance or in feel in any way one should consider probably on block resection which for a lesion this size would mean ESD. But we start the injection process in this case for EMR by going through the lesion at the distal end. We want to start the resection at the distal end that is adjacent to the skin. I think that the reason for referral and sort of like the ileocecal valve we do get a disproportionate fraction of lesions referred that are on the dentate line but the basic principles for EMR are quite similar to those elsewhere in the colon. And I like to start at the distal end and you can't be afraid to overlap the snare placement with a little bit of skin. You can get a little bit of skin resection without undue discomfort after the procedure. There also are hemorrhoidal cushions in this area and one would think there might be an increased risk of bleeding. In this case there was a little bit of bleeding from a vein that was easily stopped just off to the left of where we're injecting now using the snare tip on soft coag. In general the snare will bounce right off the hemorrhoids off the hemorrhoidal cushion and there isn't really an increased risk of bleeding. You can notice how the snare is being placed and we're bending down to get good positioning of it to get slight overlap with the squamous mucosa because this lesion is virtually abutting the margin of the skin. At times it can be helpful to have a cap on the end of the scope there you can see a little bit of cautery burn where we stopped some bleeding previously. A cap on the end of the scope may hold the anus open and improve visualization. Once you get the part of the lesion out that is closest to the dentate line no matter how big the rest of the lesion is it's just kind of a traditional EMR. When we're finished we usually use snare tip soft coag around the proximal lateral margins but I usually don't burn the skin at the distal margin with STSC. Here's another granular LST with a little bit of nodularity you can make the argument to do ESD here but I felt this was a low risk nodule and went ahead and did EMR and this came back as TVA with low grade dysplasia. I do want you to be aware that there's a literature from Michael Bork's group saying that patients can have very significant pain and they add a local anesthetic and also that these patients with lesions at the anorectal junction are at risk for sepsis and they give the patient prophylactic antibiotics. I will say that I don't do that. I've got tremendous respect for Michael's work as an investigator and there's nobody better than him as a resectionist. This is one of the only areas where I don't follow his recommendations regarding EMR and I want you to know that those recommendations are out there to use a local anesthetic in the inject data to give prophylactic antibiotics but I haven't had a problem with that except pain if you inject a lot of epinephrine. We are again starting the injection at the distal end of the lesion using a little bit of overlap with the snare. Once we're sure that that dentate line has been cleared then we use standard EMR techniques to resect the rest of the lesions STSC along the lateral and proximal borders and then that completes the EMR of the lesion at the dentate line. Thanks and see you next week on the ASGE SuTAP tip of the week.

EMR lesions

anorectal junction

granular lateral spreading lesion

adenoma

block resection