LAUSR

Hybrid endoscopic mucosal resection (H-EMR) has been described as a valid alternative to traditional EMR. This technique involves an initial submucosal injection, followed by a circumferential incision and, finally, the resection of the central tissue with a snare [1]. This strategy can be applied to lesions under 20mm in diameter, and allows the visualization and inclusion of the whole lesion, with certainty of complete en bloc resection [2]. However, H-EMR can be challenging to perform in nonlifting and difficult-toaccess lesions. The underwater H-EMR technique has the potential to overcome this limitation. We report the case of a 71-year-old man who was referred to our department for resection of a residual adenomatous 6-mm lesion, after previous incomplete removal by EMR. The access to the lesion was not easy, as it was located in the cecum on the colonic surface of the proximal ileocecal valve (▶Video 1). Submucosal injection was performed, but the lifting of the lesion was shortlived and suboptimal owing to underlying fibrosis (secondary to the previous resection attempt).We then decided to deflate the colon and infuse saline serum to completely fill the lumen. This resulted in contraction of the mucosa and submucosa, making the lesion float into the liquidfilled lumen. A circumferential incision with the tip of a hot snare was then performed around the lesion, and the surrounding tissue was safely and completely resected using the same snare. With this method, we have demonstrated that underwater H-EMR is feasible and can be useful in selected cases, by assuring complete resection of difficultto-access and nonlifting lesions.