on the ASGE SuTab tip of the week. This is a patient referred for management of serrated lesions in the cecum. I found three lesions in the cecum that we briefly saw all three of them there. This is the third one. The first one, the very first one that appeared underwent biopsy by the referring physician. And this is the third one, about 25 millimeters in diameter, which was not biopsied. And we're gonna look at the difference of how cold EMR goes with this lesion, which hasn't been biopsied, versus the first lesion we saw, which was biopsied. The third lesion, one that goes around the appendiceal orifice actually goes down into it. And we're gonna remove the periphery of that later off video, not as part of this tip. And that'll have to be dealt with, the part in the appendix, either by the full thickness resection device or by appendectomy and cecectomy. But the idea is to look at how this goes. We talked a couple of weeks ago about this process of cold EMR for serrated lesions. And this lesion has come off really just the way we'd like it to, separating very easily from the submucosa. A little bit differently than how it's gonna go with this lesion that we're injecting right now. And the difference is the submucosal fibrosis that's developed as a result of the biopsies that we're taking. What happens during the EMR is that the snare tends to slide across that fibrotic area, leaving a residual polyp in some cases. And as we're injecting it, as we get it washed off, you'll see the area where the fibrosis occurred as a crevice going from right to left across the surface of the polyp. That is where the biopsies were taken. Now we've got arrows on this crevice running from right to left across this SSL. This is a deformity that's been created by the previous biopsies. During the EMR, we can expect to encounter some submucosal fibrosis in this area that will make the EMR more challenging and probably more likely that we won't get a complete and effective resection. So this leads to the recommendation that when you encounter a flat lesion, unless it's got cancer in it, if you're not gonna remove it at that setting, don't biopsy it. Just note the location, tattoo it if you want, and refer it on because the biopsy will consistently produce some submucosal fibrosis, whether it's taken from the middle or from the edge. And I think this is especially true of SSLs where it's quite easy to typically see the site of biopsy and where there's some expectation of scarring and submucosal fibrosis. We're starting the cold EMR on the lesion that has fibrosis in it now. And the parts of the lesion that are away from that line of fibrosis are gonna come off as expected, but then the parts that are on top of that fibrotic area, the snare's gonna tend to slide over and it's gonna leave some residual tissue. Now, there are a couple of ways to deal with this. One is to do a hot EMR because I do think that you could place maybe a 15 millimeter snare over this lesion and possibly cut under the whole thing with electrocautery. And I actually would consider that a viable option when you can tell there's a really substantial amount of fibrosis. I wanted here to demonstrate the effect of the fibrosis. So we're trying to do the cold EMR. So we're getting close to the area of fibrosis. This piece in particular, you'll see that, that the tip of the snare is gonna slide forward as we close and it's gonna slide right across that fibrosis. There it goes, it's skipping right over some of the polyp. And as we get this off, we're gonna see that white line, that's the fibrosis. And we'll also see that there's a tendency for there to be bleeding. And often bleeding is a signal that you've resected in the wrong plane. If you cut through the polyp as opposed to under it in the submucosa, you'll tend to get more bleeding. Here there are arrows marking this line of white submucosal fibrosis across this EMR defect. Here you can see that line of fibrosis start to ooze to actively bleed right after the washing stops. And this should signal that we have transected in the wrong plane. We've left a thin layer of intact polyp and muscular submucosa on top of that submucosal fibrosis. So now we've got this thin layer of polyp tissue sitting on submucosal fibrosis and we need to deal with it. There are a variety of ways to do that. We're gonna use the cast technique that is cold forceps, avulsion, followed by snare tip, soft coagulation along that line of fibrosis. And then because we're in the thin walled cecum, I put some clips on to support the wall. But for the purposes of our discussion, the point is that the need for all of that is really created by the previous biopsies in the submucosal fibrosis that they produced. If that hadn't been done, then we would have had a straightforward cold EMR without the need for these ancillary EMR techniques. So you can see the first piece of that coming off. If you do take some biopsies, then certainly don't send the patient to surgery. Still send the patient to your interventional endoscopist. They're happy to deal with it. But going forward, if you have a tendency to do this, you can make subsequent EMR more straightforward by avoiding biopsy. Note the size and location of the lesion. Tattoo it if you think is appropriate, but avoid creation of submucosal fibrosis. Next week, can we extend cold EMR to large conventional adenomas, and how far can we take it on the ASGE SuTab tip of the week?

serrated lesions

cecum

biopsied lesions

cold EMR

submucosal fibrosis