Today, SSLs that warrant consideration of the use of electrocautery for resection, on the ASGE SuTab tip of the week. So in answering the question, should certain SSLs be removed with electrocautery rather than by cold techniques? One question that comes immediately to mind is what about the SSL with cytological dysplasia? Some SSLs with cytological dysplasia have overt evidence endoscopically of dysplasia and this is one of them. To the left hand side of this lesion, there is a small five millimeter or so area that has NICE 2 rather than NICE 1 features. You can see it to the left of the injection mound as it's developing. This is a more advanced lesion. It's considered closer to cancer in the SSL to cancer sequence. That portion of the lesion has been shown in micro dissection studies to have microsatellite instability. However, there's going to be some variation of opinion about this. I would still feel it's acceptable to remove this by entirely cold techniques for two reasons. One, it hasn't been biopsied. It does have tattoo that is underneath it, but in my experience, if the tattoo has not been injected directly underneath it, it usually doesn't cause fibrosis. There's the dysplastic portion being sneered right now. It looks like an adenoma instead of a serrated lesion and secondly, the entire lesion lifted very well. I think that even though there's dysplasia, it's okay in this instance, but I would say there probably is not complete agreement among experts with that approach. I think there will be a lot of individual twists from endoscopists about whether there's a subset of SSLs that should be removed using electrocautery. This was a lesion that I chose to remove using electrocautery. It's not very big. It's about 10 millimeters in diameter, but the referring physician had biopsied it and the biopsy showed SSL with dysplasia. As is usually the case and was the case here, you can see the exact place where the biopsy was taken and that will typically be associated with some fibrosis. If you're using a cold sneer, there is more of a tendency for the sneer to slide over the fibrotic area. Arrows are pointing to this vertical crevice about two millimeters long. That's where the biopsy was taken. The red line is around most of the area of dysplasia, which as you'd expect is immediately adjacent to the biopsy site. So I decided to use electrocautery to be sure I got under this little area of dysplasia and adjacent fibrosis. So we're using a 15 millimeter snare to perform an on block hot EMR encompassing several millimeters of normal mucosa around the lesion. Certainly there could be other good approaches to this underwater EMR might be effective in getting that fibrotic area out, even a cold technique. And then if there appears to be some residual polyp or muscularis mucosa to a vulset. I think the point is that you want to look at the surface features and if there's some combination of dysplasia or more advanced features and fibrosis, then consideration of electrocautery to enhance the effectiveness of every section could be appropriate. So the point of our discussion is that each SSL needs to be assessed for the appropriateness of piecemeal cold EMR on its own merits. And this is an example of a lesion that I think is not a good candidate for piecemeal cold EMR or piecemeal resection. This on biopsy by the referring physician showed SSL with high grade dysplasia. There's this red area in the middle that was quite worrisome. Electronic chromoendoscopy and magnification. I did not think it had features of NIS3 of deep semicostal invasion, but there were clearly quite advanced features. This is a lesion we want to get out on block. It's small enough to remove it by on block EMR, but clearly we want to remove it using electrocautery. Get it out in one piece, pin it to a flat surface, have the pathologist section it in a plane perpendicular to the resection margin so that if cancer is present, they can tell us the invasion depth. In fact, the final pathology of this lesion was SSL with dysplasia and a focus of adenocarcinoma with deep semicostal invasion leading to a recommendation for adjuvant surgical resection. So although the per lesion risk of cancer in SSLs is considerably lower than the per lesion risk in conventional adenomas of similar size, we do see SSLs with advanced histology and cancer. And before considering cold piecemeal resection, each lesion should be evaluated for the extent of fibrosis from prior biopsy or resection and the entire surface examined for endoscopic features predicting advanced histology or cancer. We often hear that we should avoid biopsy prior to referral of flat lesions for EMR. Next week we'll see why on the ASGE SuTab tip of the week.

electrocautery

sessile serrated lesions

gastrointestinal tract

cytological dysplasia

cold techniques