that occurred during EMR on the ASGE SUTAB tip of the week. Type 4 and 5 muscle injury during EMR, that's perforation without and with contamination. This is a rare event during EMR. In my entire career, I've just had a handful of these. Looking back, I would say that when it's occurred, it usually was when I was doing something that I didn't think was high risk. I wasn't anticipating severe injury. In retrospect, you can almost always think of something you could have done differently that might have prevented it. On the other hand, when I have been doing things that I thought were high risk, almost always you get away with it. So I think the point is that it could occur at any time, and you need to be prepared to deal with it. If you see contamination that is feces going through the hole, you know it's type 5. If the patient develops elevated white count and fever afterwards, that's also evidence of type 5. They won't get that from just gas going out the hole. A patient where you see no witness contamination that has no significant pain afterwards does not develop a white count or fever, then that is the type 4 injury. Again, an advantage of using hemostatic clips to close a perforation during EMR is, first of all, these perforations are typically very small, and so hemostatic clips are adequate. And then secondly, you keep the perforation under your direct vision the entire time. You have the opportunity to prevent anything from going out the opening by suctioning, and therefore maintain a type 4 perforation. And the advantage of that is although you're going to admit these people, if there is no significant pain, no development of fever or white count overnight, and you've got a good closure, you could potentially let the patient go home the next day on clear liquids and a couple of days of antibiotics. Whereas if there is type 5, there's fever and elevated white count, you need to keep them in and observe them until those resolve. Here's a type 4 muscle injury occurring during hot EMR of a serrated lesion in the right colon. Now next week, we're going to talk about the fact that we probably don't, for the most part, need to use electrocautery in the removal of serrated lesions. But we were doing that in this case, this sort of more traditional approach to EMR is to use electrocautery. And we get this perforation. Again, I was kind of surprised by this because we're kind of in a cleanup phase of this EMR. We're using a small snare, a 10 millimeter snare. I was using cutting current. Maybe that was, in retrospect, an issue. But certainly, I've used cutting current, thousands of different cuts in various EMRs without this kind of result. The patient jumped. In retrospect, I think they jumped because of the perforation. The jumping didn't cause the perforation. I thought that was interesting that when you cut through the serosa, that even though the patient was deeply sedated, they might feel that. We are going to clean this up. But when a perforation like this occurs, there's a couple things that you want to do. The first one is stop putting any kind of fluid into the colon. We don't want anything to go out that hole, either a stool or material that we put in the colon. So we're suctioning, but we're not washing at all. And the second thing is we're getting somebody to put their hand on the patient's abdomen. We're trying to limit the amount of gas that we insufflate, and we're going to monitor to make sure that they don't develop a significant pneumoperitoneum, anything that could compromise them and start any sort of abdominal compartment syndrome. Obviously, we're using CO2, but still we don't want them to get distended. Now we're starting the clipping process. You notice that we put the first clip actually not over, but next to the perforation, sort of drawing the tissue together so that the one that goes over the perforation is really going to be tight. We're also trying to bury the clips. We're actually going to close this whole EMR defect, but especially in the area where the perforation was, we're going to put clips tightly together. Here you can see that we're slipping a clip in between the first two clips so that the clips are really adjacent to each other in this tight closure. And this appears to be a type 4 perforation because so far we haven't seen anything go out the hole. And then finally, we also want to go over the top of the clips, bend them down, and make sure that it looks nice and closed from the proximal side. So this is type 4 because there's no witnessed contamination with fluid or feces. Some gas goes out the hole, yes, but as long as there's not overdistension, gas itself is not harmful. CT showed a small amount of gas above the diaphragm, no fluid in the peritoneal cavity. The patient had no post-procedural pain, normal white count, and no fever. Went home the following day on another day of clear liquids and a couple of days antibiotics. So here is a type 5 muscle injury occurring during EMR. That is a perforation with evidence of contamination. This is a granular LST in the transverse colon. Again, we have to respect the transverse colon along with the cecum. These locations have the highest risk of muscle injury. There's some tattoo off to the left. I don't think that had anything to do with it. I did try to remove this essentially on block, and there is some normal mucosa on the proximal side of it, and that's actually where the perforation occurred. I don't think that's all that unusual during EMR, so it was a bit unexpected, but perhaps in retrospect, too large a piece of tissue removed in one piece. You can immediately see a type 3 muscle injury in the defect. The arrows are on the cut muscle. So this type 3 muscle injury then quickly became a free perforation, and during the closure, I saw some mucoid material go out the hole, so that made it a type 5 muscle injury. The patient did have an elevated white blood cell count and a fever that night, had some discomfort. All of those resolved on the following day, was observed in the hospital for a couple of days on clear liquids and antibiotics. The endoscopic treatment, basically the same, using hemostatic clips to perform a tight closure with the clips closely spaced, trying to bury them. That first clip really not very well buried, but went back and put another clip on the left-hand side. In the end, this provides an effective closure for small EMR-related perforations. Next week, we move to preventing complications of EMR by using cold resection, beginning with SSLs on the ASGE SUTAB tip of the week.

Type 4 muscle injuries

Type 5 muscle injuries

EMR procedures

hemostatic clips

complications