Endoscopic resection in Barrett’s: ER-cap, MBM or ESD?

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Endoscopic resection in Barrett’s: ER-cap, MBM or ESD?. In general: Unifocal, limited size (< 2cm); Mucosal lesions; Well / moderately differentiated neoplasia: How do I know it’s mucosal? Endoscopic appearance; Endoscopic ultrasound ER as a diagnostic procedure. - PowerPoint PPT Presentation

Text of Endoscopic resection in Barrett’s: ER-cap, MBM or ESD?

  • Endoscopic resection in Barretts: ER-cap, MBM or ESD?

  • Indications for ER in BarrettsIn general:Unifocal, limited size (< 2cm);Mucosal lesions;Well / moderately differentiated neoplasia:How do I know its mucosal?Endoscopic appearance;Endoscopic ultrasoundER as a diagnostic procedure

  • Treatment concept and considerations IMCHGIN LGINsuperficial sm invasionERRFASurgerydeepsm invasion

  • All visible lesions or suspicious areas require endoscopic resection!

    Treatment concept and considerations

  • Submucosal liftingLifting sign (Adrenalin 1:20.000)(Kato et al, Endoscopy 2001, 33: 568-573)Kato type 1: complete/softKato type 2: complete/hardKato type 3: incompleteKato type 4: non-lifting sign

  • Start with injecting at the distal margin;In tubular esophagus: lesion at 6 oclock position;In distal esophagus: retroflex;Insert the needle tangential to esophageal wall;Start fluid injection just before insertion;Start injecting at the edges;Avoid injection through lesion.Submucosal liftingInjection Technique

  • Submucosal lifting

  • All sm1-sm3Submucosal liftingType 3: Incomplete lifting

  • All sm3Submucosal liftingType 4: no lifting sign

  • ER-cap, MBM or ESD?

  • ER-cap vs.MBM techniqueRandomised trialPouw et al. Gastrointest. Endosc. 2011

  • Piecemeal ER with MBM is faster and cheaper than with the ER-cap technique;MBM may be associated with fewer complications;MBM results in significantly smaller sized resections;MBM may, therefore, be more suited for resection of flat lesions with a low risk of submucosal invasion;The ER-cap technique may be preferred for ER of elevated and nodular lesions. ER-cap vs.MBM techniqueRandomised trialPouw et al. Gastrointest. Endosc. 2011

  • ER-cap technique

  • ER-capsHard caps, straight or oblique, : 12.8-14.8 mm.

    Hard, wide caps, straight or oblique, : 16.1 mm.

    Large flexible oblique caps, : 18 mm.

  • Oblique caps for most lesions.Straight caps only for lesions that can be approached en-face (e.g. greater curvature stomach). Size of the cap = size of specimen.Size of the cap = depth of resection.General rule

    Large caliber cap for en-bloc resections.

    Standard cap for piecemeal resections.Matzusaki et al Gastrointest. Endosc.2003ER-capsGeneral rules

  • Different diameters to fit differently sized endoscopes.Choose right cap for endoscope.Fix with water resistant tape.Introduction hard cap can be difficult.ER-caps

  • Crescent shaped, single use ER snareER-cap procedureSnares

  • Snare is placed in the distal ridge inside the cap.Position cap at an area with normal mucosa.Seal (not fill) the cap with gentle suction.Open snare slowly, keep tip at 6-9 position. Ideally the snare should open clockwise.ER-cap procedureSnare placement

  • ER-cap procedureSnares

  • Location lesion prior to resectionPosition the lesion at 6 oclock

  • Location lesion prior to resectionPosition the lesion at 6 oclock

  • For lesions at the 12 oclock position:

  • Avoid resection with the endoscope in an angulated position

  • Rotate the endoscope to position the lesion at the 6 oclock position

  • Suck and catchTest suction prior to placement of snare may be useful.Amount of aspiration of mucosa in cap determines size resected specimen.En-bloc resections: go for complete red-out, be more conservative for piecemeal procedures.Tighten snare quickly until resistance is encountered.

  • ResectionResect outside the cap.Hold the snare by yourself!Re-open 1-2 mm, inflate esophagus and shake specimen.Pre-coagulation for 1-2 seconds.Use either coagulation or Endocut for further resection.Erbe ICC 200: pre-coagulation: 1-2 sec 45 Watt. transsection: Endocut 120 Watt, effect 3.

  • Suck, shake and cut

  • Multi-Band Mucosectomy (DuetteR)

  • Multi-Band Mucosectomy (DuetteR)

    Modified variceal band ligator:Widened threading channel of the cranking device from 2 to 3.2 mm, allowing introduction of 7F accessories alongside the thread. 7F accessories: Not only a snare, but also an APC probe, spraying catheter, clipping device or hot biopsy forceps.

  • Multi-Band Mucosectomy (DuetteR) Transparent cap with 6 rubber bands, to create a pseudopolyp; Hexagonal snare for resection using electrocautery, reusable due to shape stability.

  • A pseudopolyp is created by suctioning mucosa into the cap, and releasing a rubber band; The snare should be placed below the rubber band; The snare should be closed tighter than with the cap-technique; Use pure coagulation (ICC 200, 45 W), usually the polyp is resected after 1 to 2 seconds.Multi-Band Mucosectomy (DuetteR)

  • Mounting of the EMR deviceDo not use the irrigation adapter of the set to puncture and widen the opening of the cranking device! Fix the Duette barrel properly.During fixing of the barrel, take care of the outer covering of the scope which may be damagedAlign trigger cords preferrably at 6-12 oclock position (Olympus scope).

  • Ensure good visualizationplace the cap correctlyXX

  • Technical difficultiesdecreased visibility due to bands and wires

    Release some bands if you expect to perform en-bloc resection.

  • ModelEndoscope SnareWorking channel DT-69.5-13mm7-Fr3.7DT-6-5F9.5-13mm5-Fr2.8DT-6-XL11-14mm7-Fr3.7

  • Piecemeal ER in BE using MBM

  • Before ER Therapeutic endoscope preferred due to better suction ability;Clean the area for ER of any secretion;Marking of the lesion by APC:2-5 mm outside the lesions marginsTip of snare: Erbe ICC 200, 45 Watt APC: Erbe ICC 200 + APC 300, 40 Watt.Suck out all fluids from the stomach !!!

  • Piecemeal ERWhat to target first?Try to remove the most involved area in a single piece, usually in the first resection; The lateral edges of each resection are the most superficial so avoid cutting through the area where you expect the deepest infiltration.

  • Target the second resection area;Variables:Relative position of the cap to the resection wound; Size of the cap;Amount of aspiration of mucosa into the cap.ER-cap: repeat lifting before every subsequent resection;Always perform a test suction (and prior to placement of snare when using ER-cap).Piecemeal ERSubsequent resections

  • Herrero A. et al. Endoscopy 2011;43:177Soehendra N. et al. GIE 2008; Safety and efficacy of multiband mucosectomy in 1060 resections in Barrett's esophagus

    Prospective registration Complications n=170 (resections: 1060)Perforation 0% (0/243)Delayed bleeding 2.1% (5/243)

  • En-bloc vs. Piecemeal ERpiecemeal resectionEnables widespread ER;Technically more challenging than en-bloc resections;Bigger risk of complications;Recurrences appear more often after piecemeal procedures.

  • Practical aspectsTips & Tricks I

    To prevent perforation do not suck too much at the EG junction and in a hiatal hernia.

    Avoid "red out phenomenon (suction of the tissue all the way to the lens).

  • Torque the scope to appropriately locate the lesion according to the distal opening of the working channel to facilitate snaring.

    Avoid touching the pseudopolyp: do not move the barrel beyond the pseudopolyp extend and open the snare beyond the pseudopolyppull the opened snare back and place it around the pseudopolyp

    Practical aspectsTips & Tricks II

  • Overlap vs. irradical resectionAvoid too much overlap to prevent perforation;Less than 25% overlap is acceptable: resection is usually less deep at the overlapping lateral margins than at the centre of the resection;Avoid residual Barretts tissue between adjacent resections;Be liberal with submucosal injection in the resection area.

  • Additional ablation residual tissueAPC 60-80 WattUseful in case of (very) small residual isles of target tissue between subsequent resections or between markings and the outer wound margin.

  • Retrieval specimensAlways retrieve specimens for histopathological evaluation.This can be done at the end of the procedure.Retrieval: aspirate in cap (single specimen) or foreign body basket (multiple specimens).Pin specimen on paraffin/cork before fixation.

  • ESD

  • ESD in early Barrett's cancer ? Deprez P. et al. DDW 2010

    ER Cap ESDpEn-bloc resectionnone (1-11 pieces)96%

  • Neuhaus H. et al. DDW 2010n=18 (3f/15 m)HGIN/IMC up to 3cmmedian diameter: (15-30 mm)"en bloc" resection: 15 (83.9%)Pneumomediastinum: 1Horizontal free margin: 5 (28%)

    ESD in early Barrett's cancer ?

  • Considerable for "visible lesions" larger than 2 cm. ESD in early Barrett's cancer ?

  • Wound inspection and treatment of complications

  • Treatment algorithm post-ER bleeding

  • Treatment of post-ER bleeding with the tip of the snare (ICC200 45 Watt)

  • Treatment using hot biopsy forceps (ICC 200 soft coag, 80 W)

  • What to do in case of a perforation?Esophageal Gastric Transmural resection specimen

  • Immediate management of esophageal perforationsPlace suction tube at the site of the perforation.Limit inflation (emphysema).Esophagography watery contrast medium.

  • Perforations Surgical or conservative treatment?Have you completely eradicated the neoplasia?Will surgery be required anyway?Whats the size and the location of the defect?Surgery is easier for gastric than esophageal perforations.Small defects may be treated endoscopically.Does the patient have relevant co-morbidity? Beware: optimal timing for surgery is