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

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  • Endoscopic Mucosal ResectionDr. Howard MertzClinical Assistant ProfessorVanderbilt UniversitySaint Thomas Hospital Nashville TN

  • AcknowledgementsWilson Cook support for this presentationOlympus support for EMR training

  • Background:Endoscopic removal of superficial lesions in the GI tract feasibleThis allows full pathologic evaluation superior to surface biopsiesCan be curativeCan prevent surgery

  • Background:Endoscopic Mucosal Resection (EMR) now done more widely and safelyTargetsLarge sessile colon polypsEsophageal dysplasia or early cancersGastric cancers or benign tumor nodulesDuodenal polyps

  • 5 Layers of the GI tract by EUSEUS HistologyMucosa

    MMSubMuc

    MPSerosa

  • Submucosal (SM) InvasionIncreases risk of lymph node metastasesEsoph 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 EMRIf SM on path: surgery or Chemo/RT

  • Patient Selection and EUS:EUS to evaluate depth except in polypsAvoid EMR if submucosal cancerNo lymphadenopathyBenign lesions deep in the submucosaAvoid if previous snaring that will tether lesion down with scar tissue

  • T1, N0 Rectal CancerMass confinedTo mucosal layer

    Can be resected Transanal or by EMR

  • Rectal Cancer T2,N0

  • Nodule in Barretts Esophagus

  • Nodule in Barretts EsophagusT1-2N1

  • Mucosal Lesion Evaluation53 yo man with heartburn and nodule inBarretts epithelium. EUS: mucosal/submucosal lesionmp>sm>

  • Submucosal Injection:Create fluid cushion in submucosaProtects muscularis propria from perforationVolumes between 5 and 20 ccUse Sclerotherapy needleInjection fluids can be normal or hypertonic saline, D50, Hyaluronic acidMethylene blue and epinephrine helpful

  • Submucosal Injection:Normal Saline 18.5 ccEpinephrine (1:10,000) 1 ccMethylene blue 0.5 cc

    If gastric, use D50 or methyl cellulose, due to faster diffusionHaber, Lennox Hill NY

  • Submucosal Injection:Start on distal side of lesionInject several locationLook for lift up of lesion over cushionFailure to lift indicates deeper penetration, contraindication to EMRMethylene blue shows the cushion

  • Marking TipsMark lesion with burns from needle knife or polypectomy snare tip or APCCan use indigo carmine or other dyesInject enough so cushion extends well beyond markingsSnare halfway up cushion

  • TechniquesInject and snareInject, band and snare Inject, suction cap, snare

  • DevicesInjection needleStiff snares: Hex snare best, braided helpfulCombined needle-snare (US Endo I snare)Cap EMR on EGD scopesOlympus EMR kitlargest, angled or straightCook Duettvariceal type bander, smallerRoth net for retrieval of specimens

  • Lift and Snare

  • Lift and Snare EMR

  • Inject, Cap EMR, Snare

  • Inject, Band, Snare

  • Mucosal Lesion Evaluation53 yo man with heartburn and nodule inBarretts epithelium. EUS: mucosal/submucosal lesionmp>sm>

  • Endoscopic Mucosal ResectionSubmucosal Elevation Banding Snare Injection ResectionPathology: inflammatory polyp in Barretts

  • Inject, Cap EMR, Snare

  • How to Ensure Successful EMRCase selection: avoid non-lifting, difficult to access, near circumfrential diseaseCan be more aggressive in rectumAttempt en bloc resection when possibleCarefully resect, biopsy, burn residualClose follow up < 6 months to recheck siteDiscuss option of surgery

  • Risk of PerforationHighest Duodenum Colon, Esophagus Stomach Rectum LowestReported Rates 0.1-5%

  • How to minimize PerforationAvoid hot biopsy forceps if possibleEnsure good mucosal lift before snaringReinject saline if EMR taking more time and cushion diffusing outLift with snare prior to cauterizing

  • Bleeding RiskSize < 1cm0%Size 1-2 cm4%Size 2-3 cm24%Size >3 cm32%By Site: Esophagus 11%, Stomach 28%, Duodenum 33%, Colon 17%

  • How to Minimize BleedingSlow steady closure of snare during cauteryBlended current or all coagArgon laser to cauterize and bleedersNo anti-coagulants or NSAIDS for 2 weeks May avoid epi to allow any bleeding to be overt initially

  • SummaryEMR is available and feasibleRequires expertise, EUS helpfulComplications include perforation (approx 2%) and bleeding (approx 6%)Curative if mucosal disease onlyCan prevent surgery