Expert live case teaching piecemeal EMR of a large sessile transverse colon polyp, covering optical assessment with BLINK criteria, underwater and injection-assisted resection, intraprocedural bleeding management, and clip closure.
Intraprocedural bleeding management - demonstrates the cap-water-identify precision framework for managing arterial bleeding during piecemeal EMR
"Before we resect anything, we need to characterise this polyp using BLINK criteria to determine the best resection strategy."
Large sessile polyps in the transverse colon represent one of the most common yet technically demanding scenarios in therapeutic colonoscopy. This expert live case demonstrates the complete workflow for managing a bulky transverse colon polyp using piecemeal endoscopic mucosal resection (EMR), from initial optical assessment through to defect closure.
"Watch how the underwater view gives us superior visualisation of the polyp margins compared to traditional air insufflation."
The case begins with systematic polyp characterisation using the BLINK optical diagnosis framework. The operator methodically evaluates surface pit pattern, vascular architecture, and morphological features to confirm benign histology and plan the resection approach. This structured assessment is critical for determining whether en bloc or piecemeal resection is most appropriate.
"When you encounter arterial bleeding during piecemeal resection, the key is not to panic — cap the scope, fill with water, and identify the precise source."
The resection employs a hybrid approach combining underwater EMR with targeted submucosal injection. Water immersion causes the polyp to float away from the muscularis propria, creating a natural safety margin. For areas requiring additional lift, dilute adrenaline with methylene blue is injected submucosally to ensure adequate tissue elevation before snare capture.
Key technical pearls include careful snare placement at the polyp-normal mucosa junction, controlled slow closure of the snare, and systematic resection in overlapping pieces to ensure complete removal.
"Complete clip closure of the resection defect significantly reduces the risk of delayed bleeding in large EMR cases."
Perhaps the most valuable teaching moment comes during management of intraprocedural arterial bleeding. The operator demonstrates a structured precision framework: cap the endoscope tip against the bleeding point, fill the lumen with water for improved visualisation, then systematically identify the exact bleeding vessel.
The bleeding is controlled with targeted soft coagulation using the snare tip, applied directly to the identified vessel. The operator explains why this approach is preferred over clip placement at this stage, as clips can interfere with completion of the resection.
"The decision between en bloc and piecemeal comes down to polyp size and morphology — above 20mm in the colon, piecemeal EMR remains the pragmatic choice."
Following the bulk of the piecemeal resection, the operator performs meticulous inspection of the resection margins using white light and NBI (narrow band imaging). Small islands of residual adenomatous tissue are identified and treated with snare-tip soft coagulation (STSC), ensuring complete eradication while minimising thermal injury to the deeper wall layers.
The case concludes with systematic clip closure of the mucosal defect. The operator demonstrates an efficient zipper technique, placing clips from one edge to the other to achieve complete closure. This step is emphasised as particularly important for transverse colon lesions, where the wall is thinner and the risk of delayed perforation or bleeding is higher.
Watch the full 72-minute procedure to see every step of this complex piecemeal EMR from optical assessment through to complete defect closure.
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