Endoscopic resection in Barrett’s:

ER-cap, MBM or ESD?

Indications for ER in Barrett’s

• 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

Histological evaluation ER specimen:The most important step of the diagnostic work-up.

IMCHGIN LGIN superficial sm invasion

ERRFA Surgery

deepsm invasion

Treatment concept and considerations

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/soft

Kato type 2: complete/hard

Kato type 3: incomplete

Kato type 4: “non-lifting sign”

• Start with injecting at the distal margin;• In tubular esophagus: lesion at 6 o’clock 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-sm3

X XSubmucosal lifting

Type 3: Incomplete lifting

All sm3

XSubmucosal liftingType 4: “no lifting” sign

ER-cap, MBM or ESD?

ER-cap vs.MBM techniqueRandomised trial

ER-cap ER-cap (n=22)(n=22)

MBM MBM (n=23)(n=23)

p-p-valuevalue

Number of resections/procedure 4 (2-8) 5 (3-9) nsProcedure time (min) 50 (29-65) 29 (16-52) 0.04No. complications: Severe (perforation) Mild (bleeding)

212

09

nsns

Max. diameter of ER-specimens (mm) 21 (19-25) 18 (15-20) 0.00Max. thickness of ER-specimens (mm)

2.0 (1.80-2.20)

1.9 (1.6-2.15)

0.393

Max. thickness of submucosa (mm) 1.0 (0.50-1.13)

0.8 (0.55-1.00)

0.363

Costs disposables/procedure, euro’s 322 (275-474)

240 (240-484)

0.010.01Pouw 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 trial

Pouw et al. Gastrointest. Endosc. 2011

ER-cap technique

ER-caps• Hard caps, straight or oblique,

Ø: 12.8-14.8 mm.

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

• Large flexible oblique caps, Ø: 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.2003

ER-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 snare

ER-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 resection

Position the lesion at 6 o’clock

Location lesion prior to resection

Position the lesion at 6 o’clock

For lesions at the 12 o’clock position:

Avoid resection with the endoscope in an angulated

position

Rotate the endoscope to position the lesion at the 6

o’clock position

Suck and catch• Test 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.

Resection• Resect 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)

• 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.

Multi-Band Mucosectomy (DuetteR)

• 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 device

• Do 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 damaged• Align trigger cords preferrably at 6-12 o´clock

position (Olympus scope).

Ensure good visualizationplace the cap correctly

X X

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

Technical difficultiesdecreased visibility due to bands and

wires

Model Endoscope Snare Working channel

DT-6 9.5-13mm 7-Fr 3.7

DT-6-5F 9.5-13mm 5-Fr 2.8

DT-6-XL 11-14mm 7-Fr 3.7

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 lesion’s margins– Tip 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

Prospective registration Complications

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

(5/243)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

En-bloc vs. Piecemeal ERpiecemeal resection

•Enables 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

pseudopolyp– pull the opened snare back and place it around

the pseudopolyp

Practical aspectsTips & Tricks II

Overlap vs. irradical resection

• Avoid 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 Barrett’s tissue between adjacent resections;

• Be liberal with submucosal injection in the resection area.

Additional ablation residual tissue

APC 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 specimens• Always 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 ? ER Cap ESD p

En-bloc resection none (1-11 pieces)

96% <0.0001

Surface resected mm2

1488 (185-3194) 2453 (600-5400)

<0.01

time (min) 61(20-130) 150 (64-334) <0.001Devices costs (Euro)

264 (60-515) 486 (247-1019) <0.001

R0 (free lat & deep margins)

24% 64% <0.05

CR neoplasia 100% 100% nsCR intest metaplasia

84 84 ns

Perforation 1 2 ns

Deprez P. et al. DDW 2010

Neuhaus H. et al. DDW 2010

• n=18 (3f/15 m)• HGIN/IMC up to 3cm• median diameter: (15-30 mm)• "en bloc" resection: 15 (83.9%)• Pneumomediastinum: 1• Horizontal 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 bleedingBleeding after endoscopic resection

Minor oozing Spurting bleeding

Observe for 1-2 min. ORcareful coagulation with tip of snare

Grasp vessel/bleeding area with coagulation forceps (max. 2 times)

If unsuccessful or inadequate visualization:

•Reposition patient?;•Inject adrenaline 1:10,000 (2-5 cc)

and repeat coagulationOR•Place hemoclip.

-

-

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 Esophageal Gastric Gastric Transmural resection Transmural resection specimenspecimen

Immediate management of esophageal perforations

• Place 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?

• What’s 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 <24 hours.

PerforationsNon-surgical management

• Close defect with clips (stomach).

• Place covered stent.

• Antibiotics and PPIs.

• Nil per mouth.

Treatment of perforationsplacement of a covered stent

Perforation as seen through the cap

Conservative treatment by stent placement

Healed esophagus after 8 weeks

Treatment of perforationsperforation closed with clips and an

endoloop"tulip bundle technique'

Perforation as seen through the cap

Perforation closed with clips and an endoloop

Healed esophagus after 4 months

Questions?