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Endoscopic Mucosal Resection Dr. Howard Mertz Clinical Assistant Professor Vanderbilt University Saint Thomas Hospital Nashville TN

Endoscopic Mucosal Resection Dr. Howard Mertz Clinical Assistant Professor Vanderbilt University Saint Thomas Hospital Nashville TN

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Page 1: Endoscopic Mucosal Resection Dr. Howard Mertz Clinical Assistant Professor Vanderbilt University Saint Thomas Hospital Nashville TN

Endoscopic Mucosal Resection

Dr. Howard Mertz

Clinical Assistant Professor

Vanderbilt University

Saint Thomas HospitalNashville TN

Page 2: Endoscopic Mucosal Resection Dr. Howard Mertz Clinical Assistant Professor Vanderbilt University Saint Thomas Hospital Nashville TN

Acknowledgements

• Wilson Cook support for this presentation

• Olympus support for EMR training

Page 3: Endoscopic Mucosal Resection Dr. Howard Mertz Clinical Assistant Professor Vanderbilt University Saint Thomas Hospital Nashville TN

Background:

• Endoscopic removal of superficial lesions in the GI tract feasible

• This allows full pathologic evaluation superior to surface biopsies

• Can be curative

• Can prevent surgery

Page 4: Endoscopic Mucosal Resection Dr. Howard Mertz Clinical Assistant Professor Vanderbilt University Saint Thomas Hospital Nashville TN

Background:

• Endoscopic Mucosal Resection (EMR) now done more widely and safely

• Targets

– Large sessile colon polyps

– Esophageal dysplasia or early cancers

– Gastric cancers or benign tumor nodules

– Duodenal polyps

Page 5: Endoscopic Mucosal Resection Dr. Howard Mertz Clinical Assistant Professor Vanderbilt University Saint Thomas Hospital Nashville TN

5 Layers of the GI tract by EUS

EUS Histology

Mucosa

MMSubMuc

MPSerosa

Page 6: Endoscopic Mucosal Resection Dr. Howard Mertz Clinical Assistant Professor Vanderbilt University Saint Thomas Hospital Nashville TN

Submucosal (SM) Invasion

• Increases risk of lymph node metastases– Esoph Ca: sm1 8-30%, sm2 23%, sm3 44%– Gastric Ca: SM 2-25%– Colon Ca: SM 10-18%

• If definite and more than superficially into SM layer by EUS, avoid EMR

• If SM on path: surgery or Chemo/RT

Page 7: Endoscopic Mucosal Resection Dr. Howard Mertz Clinical Assistant Professor Vanderbilt University Saint Thomas Hospital Nashville TN

Patient Selection and EUS:

• EUS to evaluate depth except in polyps

• Avoid EMR if submucosal cancer

• No lymphadenopathy

• Benign lesions deep in the submucosa

• Avoid if previous snaring that will tether lesion down with scar tissue

Page 8: Endoscopic Mucosal Resection Dr. Howard Mertz Clinical Assistant Professor Vanderbilt University Saint Thomas Hospital Nashville TN

T1, N0 Rectal Cancer

Mass confinedTo mucosal layer

Can be resected Transanal or by EMR

Page 9: Endoscopic Mucosal Resection Dr. Howard Mertz Clinical Assistant Professor Vanderbilt University Saint Thomas Hospital Nashville TN

Rectal Cancer T2,N0

Page 10: Endoscopic Mucosal Resection Dr. Howard Mertz Clinical Assistant Professor Vanderbilt University Saint Thomas Hospital Nashville TN

Nodule in Barretts Esophagus

Page 11: Endoscopic Mucosal Resection Dr. Howard Mertz Clinical Assistant Professor Vanderbilt University Saint Thomas Hospital Nashville TN

Nodule in Barretts Esophagus

T1-2 N1

Page 12: Endoscopic Mucosal Resection Dr. Howard Mertz Clinical Assistant Professor Vanderbilt University Saint Thomas Hospital Nashville TN

Mucosal Lesion Evaluation

53 yo man with heartburn and nodule inBarretts epithelium. EUS: mucosal/submucosal lesion

mp>sm>

Page 13: Endoscopic Mucosal Resection Dr. Howard Mertz Clinical Assistant Professor Vanderbilt University Saint Thomas Hospital Nashville TN

Submucosal Injection:

• Create fluid cushion in submucosa• Protects muscularis propria from perforation• Volumes between 5 and 20 cc• Use Sclerotherapy needle• Injection fluids can be normal or hypertonic

saline, D50, Hyaluronic acid• Methylene blue and epinephrine helpful

Page 14: Endoscopic Mucosal Resection Dr. Howard Mertz Clinical Assistant Professor Vanderbilt University Saint Thomas Hospital Nashville TN

Submucosal Injection:

• Normal Saline 18.5 cc

• Epinephrine (1:10,000) 1 cc

• Methylene blue 0.5 cc

• If gastric, use D50 or methyl cellulose, due to faster diffusion

Haber, Lennox Hill NY

Page 15: Endoscopic Mucosal Resection Dr. Howard Mertz Clinical Assistant Professor Vanderbilt University Saint Thomas Hospital Nashville TN

Submucosal Injection:

• Start on distal side of lesion

• Inject several location

• Look for lift up of lesion over cushion

• Failure to lift indicates deeper penetration, contraindication to EMR

• Methylene blue shows the cushion

Page 16: Endoscopic Mucosal Resection Dr. Howard Mertz Clinical Assistant Professor Vanderbilt University Saint Thomas Hospital Nashville TN

Marking Tips

• Mark lesion with burns from needle knife or polypectomy snare tip or APC

• Can use indigo carmine or other dyes

• Inject enough so cushion extends well beyond markings

• Snare halfway up cushion

Page 17: Endoscopic Mucosal Resection Dr. Howard Mertz Clinical Assistant Professor Vanderbilt University Saint Thomas Hospital Nashville TN

Techniques

• Inject and snare

• Inject, band and snare

• Inject, suction cap, snare

Page 18: Endoscopic Mucosal Resection Dr. Howard Mertz Clinical Assistant Professor Vanderbilt University Saint Thomas Hospital Nashville TN

Devices

• Injection needle

• Stiff snares: Hex snare best, braided helpful

• Combined needle-snare (US Endo I snare)

• Cap EMR on EGD scopes– Olympus EMR kit—largest, angled or straight– Cook Duett—variceal type bander, smaller

• Roth net for retrieval of specimens

Page 19: Endoscopic Mucosal Resection Dr. Howard Mertz Clinical Assistant Professor Vanderbilt University Saint Thomas Hospital Nashville TN

Lift and Snare

Page 20: Endoscopic Mucosal Resection Dr. Howard Mertz Clinical Assistant Professor Vanderbilt University Saint Thomas Hospital Nashville TN

Lift and Snare EMR

Page 21: Endoscopic Mucosal Resection Dr. Howard Mertz Clinical Assistant Professor Vanderbilt University Saint Thomas Hospital Nashville TN

Inject, Cap EMR, Snare

Page 22: Endoscopic Mucosal Resection Dr. Howard Mertz Clinical Assistant Professor Vanderbilt University Saint Thomas Hospital Nashville TN

Inject, Band, Snare

Page 23: Endoscopic Mucosal Resection Dr. Howard Mertz Clinical Assistant Professor Vanderbilt University Saint Thomas Hospital Nashville TN

Mucosal Lesion Evaluation

53 yo man with heartburn and nodule inBarretts epithelium. EUS: mucosal/submucosal lesion

mp>sm>

Page 24: Endoscopic Mucosal Resection Dr. Howard Mertz Clinical Assistant Professor Vanderbilt University Saint Thomas Hospital Nashville TN

Endoscopic Mucosal Resection

Submucosal Elevation Banding Snare Injection Resection

Pathology: inflammatory polyp in Barretts

Page 25: Endoscopic Mucosal Resection Dr. Howard Mertz Clinical Assistant Professor Vanderbilt University Saint Thomas Hospital Nashville TN

Inject, Cap EMR, Snare

Page 26: Endoscopic Mucosal Resection Dr. Howard Mertz Clinical Assistant Professor Vanderbilt University Saint Thomas Hospital Nashville TN

How to Ensure Successful EMR

• Case selection: avoid non-lifting, difficult to access, near circumfrential disease

• Can be more aggressive in rectum

• Attempt en bloc resection when possible

• Carefully resect, biopsy, burn residual

• Close follow up < 6 months to recheck site

• Discuss option of surgery

Page 27: Endoscopic Mucosal Resection Dr. Howard Mertz Clinical Assistant Professor Vanderbilt University Saint Thomas Hospital Nashville TN

Risk of Perforation

• Highest

– Duodenum

– Colon, Esophagus

– Stomach

– Rectum

• Lowest

• Reported Rates 0.1-5%

Page 28: Endoscopic Mucosal Resection Dr. Howard Mertz Clinical Assistant Professor Vanderbilt University Saint Thomas Hospital Nashville TN

How to minimize Perforation

• Avoid hot biopsy forceps if possible

• Ensure good mucosal lift before snaring

• Reinject saline if EMR taking more time and cushion diffusing out

• Lift with snare prior to cauterizing

Page 29: Endoscopic Mucosal Resection Dr. Howard Mertz Clinical Assistant Professor Vanderbilt University Saint Thomas Hospital Nashville TN

Bleeding Risk

• Size < 1cm 0%

• Size 1-2 cm 4%

• Size 2-3 cm 24%

• Size >3 cm 32%

• By Site: Esophagus 11%, Stomach 28%, Duodenum 33%, Colon 17%

Page 30: Endoscopic Mucosal Resection Dr. Howard Mertz Clinical Assistant Professor Vanderbilt University Saint Thomas Hospital Nashville TN

How to Minimize Bleeding

• Slow steady closure of snare during cautery

• Blended current or all coag

• Argon laser to cauterize and bleeders

• No anti-coagulants or NSAIDS for 2 weeks

• May avoid epi to allow any bleeding to be overt initially

Page 31: Endoscopic Mucosal Resection Dr. Howard Mertz Clinical Assistant Professor Vanderbilt University Saint Thomas Hospital Nashville TN

Summary

• EMR is available and feasible

• Requires expertise, EUS helpful

• Complications include perforation (approx 2%) and bleeding (approx 6%)

• Curative if mucosal disease only

• Can prevent surgery