Endoscopic mucosal resection: treatment of neoplasia

Endoscopic mucosal resection of a bile duct polyp: A case report

BACKGROUND

Bile duct polyps are difficult to diagnose and are usually excised by open abdominal surgery or snare polypectomy using choledochoscopy via the T-tube sinus tract. However, these two resection methods require the surgeon to open the abdomen and cut the bile duct to place the “T” tube. Moreover, simple snare polypectomy, without submucosal injection, can only remove pedunculated polyps and not flat polyps. Therefore, a new method is required for the excision of bile duct polyps, including flat polyps.

CASE SUMMARY

A 63-year-old woman was hospitalized following epigastric pain lasting a month. She had a 30-year history of cholelithiasis and had undergone cholecystectomy because of cholecystolithiasis, and had undergone cholangiolithotomy twice due to choledocholithiasis. Computed tomography (CT) and magnetic resonance imaging showed a communication between the bile duct and duodenal bulb. Inside the communication, CT showed a high-density shadow which was a hypointense lesion in T2 weighted image. The lesion showed no enhancement in T1 weighted image contrast enhanced. Gastroscopy revealed an incarcerated bile duct stone in the anterior wall of the duodenal bulb, which was removed with a basket under gastroscopy. Thereafter, a choledochoduodenal fistula was revealed. Finally, a flat polyp was detected in the lower part of the common bile duct and was removed by endoscopic mucosal resection (EMR) through the fistula. To our knowledge, this is the first reported case of the removal of a bile duct polyp using EMR.

CONCLUSION

EMR is a safe, effective, and low-cost method for the resection of all bile duct polyps.

Transjugular Intrahepatic Portosystemic Shunt Prior to Endoscopic Mucosal Resection for Barrett's Esophagus in the Setting of Varices

Patients with Barrett's esophagus (BE) and cirrhosis who develop high-grade dysplasia (HGD) or adenocarcinoma in the setting of esophageal varices present a unique therapeutic dilemma. There is limited literature regarding the optimal management of varices prior to invasive procedures or surgery involving the distal esophagus. We present a case of variceal decompression with a transjugular intrahepatic portosystemic shunt (TIPS) allowing for successful endoscopic mucosal resection (EMR) of BE with HGD overlying esophageal varices.

Diagnostic accuracy of probe-based confocal laser endomicroscopy in detecting residual colorectal neoplasia after EMR: a prospective study

BACKGROUND

Residual neoplasia after EMR of colorectal lesions is common. There is a critical need for imaging methods to accurately diagnose residual disease and to guide retreatment in real time.

OBJECTIVE

The aim was to estimate and compare the accuracy of virtual chromoendoscopy (VCE) and probe-based confocal laser endomicroscopy (pCLE) for detection of residual neoplastic tissue at the site of prior EMR.

DESIGN

Prospective, blind, pilot comparison of advanced endoscopic imaging (VCE and pCLE) by using matching histology as reference standard.

SETTING

Three tertiary-care referral hospitals.

PATIENTS

This study involved 92 participants who underwent follow-up colonoscopies for the evaluation of prior EMR sites within 1 year.

INTERVENTION

The EMR scars were assessed during follow-up high-resolution colonoscopy by using VCE (narrow-band imaging/Fujinon Intelligent Color Enhancement [FICE]), and pCLE. Confocal videos of EMR scars were interpreted in real time and were also stored and reviewed offline, blinded to histopathology and endoscopic appearance. Tissue confirmation by biopsies or polypectomy/repeat EMR was performed in all cases.

MAIN OUTCOME MEASUREMENTS

Sensitivity, specificity, and accuracy for VCE and pCLE alone and in combination against histopathology as the standard reference standard.

RESULTS

Among 129 EMR scars, residual neoplasia was confirmed by histology in 29 sites (22%). For VCE, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were 72%, 77%, 49%, 91%, and 77%, respectively, and were 97%, 77%, 55%, 99%, and 81% for pCLE (P = .045 for sensitivity). When only EMR scars for which VCE and pCLE agreed on the diagnosis were analyzed (95/129 scars), the accuracy, sensitivity, specificity, PPV, and NPV of pCLE and VCE were 90%, 100%, 87%, 67%, and 100%, respectively.

LIMITATIONS

Small sample size, lack of power, involvement of highly experienced pCLE experts.

CONCLUSION

Confocal endomicroscopy significantly increases the sensitivity for detecting residual neoplasia after colorectal EMR compared with endoscopy alone. When confocal endomicroscopy is used in combination with VCE, the accuracy is extremely high, and sensitivity approaches that of histopathology. Together, they may reduce the need for histologic examination and allow a highly accurate on-table decision to treat again or not, thus avoiding unnecessary repeat procedures. (

CLINICAL TRIAL REGISTRATION NUMBER

00874263.).

[Endoscopic mucosal resection of colorectal tumors--our first experience]

BACKGROUND/AIM

Endoscopic mucosal resection (EMR) or mucosectomy is an interventional procedure for minimal invasive endoscopic removal of benign and malignant digestive tract tumors. Mucosectomy removes flat and sessile neoplasms, early colorectal cancer (CRC) confined to mucosa or submucosa and lateral spreading tumors. The aim of the study was to show our first experience in application of this procedure in everyday practice in regarding completeness and efficacy of the procedure, complication rate and incidence of recurrent adenomas.

METHODS

In the prospective study 51 colorectal adenomas were removed in 44 patients by EMR.

RESULTS

Single mucosectomy was done in 43 patients, while multiple (8) in one patient. Complete resection was obtained in all procedures. In 36 (68.62%) procedures "en block" resection was done, but in 15 (31.37%) procedures "piece meal" resection was performed. Synchronous colorectal tumors (benign or malignant) were detected in 20 (45.45%) patients. Moderate dysplasia was found in 30 (58.82%) adenomas, but high grade dysplasia in 9 (17.64%) of adenomas. Intramucosal CRC was detected in 11.77% of adenomas. A total of 37 (72.54%) advanced adenomas were removed. There were 3 (5.88%) of recurrent adenomas, 6-30 months after the EMR. Only one (2.2%) case of post procedure bleeding was observed.

CONCLUSION

EMR is a safe and efficious method for removal of flat, sessile adenomas, as well as early CRC. EMR is a routine endoscopic procedure in everyday practice of interventional endoscopist.

Endoscopic versus surgical therapy for early cancer in Barrett's esophagus: a decision analysis

BACKGROUND

Esophagectomy for early esophageal adenocarcinoma is associated with increased operative mortality and morbidity, but possibly a decreased recurrence rate compared with endoscopic therapy when using EMR and radiofrequency ablation.

OBJECTIVE

To compare the cost-effectiveness of esophagectomy and endoscopic therapy in the treatment of early esophageal adenocarcinoma.

DESIGN

Decision analysis model.

MAIN OUTCOME MEASUREMENTS

Incremental cost-effectiveness ratio.

RESULTS

During the 5-year study period, endoscopic therapy cost $17,000.00 and yielded 4.88 quality-adjusted life years, compared with $28,000.00 and 4.59, respectively, for esophagectomy. Varying the recurrence rates of cancer or Barrett's esophagus metaplasia after endoscopic therapy did not change the overall outcome. The sensitivity analysis demonstrated, however, that the outcome depended on the rate of lymph node involvement and operative mortality. Under the best of circumstances in favor of esophagectomy, such as 2% operative mortality, no reduced quality of life after esophagectomy, and a low 5-year survival rate after recurrence of endoscopic ablation, the risk of positive lymph nodes still needed to exceed 25% before esophagectomy became the preferred treatment option. This threshold is twice as high as the values reported for early submucosal cancer invasion.

LIMITATIONS

Limited data are available about the long-term outcome of EMR and radiofrequency ablation.

CONCLUSIONS

Endoscopic therapy for early Barrett's esophagus adenocarcinoma is more effective and less expensive than esophagectomy. Even in early esophageal adenocarcinoma with submucosal invasion, endoscopic therapy is a cost-effective alternative to esophagectomy, especially in patients with a high operative risk.

Endoscopic mucosal resection of colonic lesions: current applications and future prospects

The introduction of submucosal fluid injection has remarkably extended the range of endoscopically resectable polyps. The limiting factor for endoscopic resection is not polyp size, but polyp depth. Endoscopic ultrasound is a useful adjunctive diagnostic tool to assess the depth of invasion. The success of are section ultimately depends on pathologic confirmation of a benign nature of this lesion or of a cancer limited to the mucosa. Selected well-differentiated cancers without lymphovascular invasion of the superficial submucosa can be successfully resected endoscopically.

Gastric full-thickness suturing during EMR and for treatment of gastric-wall defects (with video)

BACKGROUND

The endoscopic full-thickness Plicator device was initially developed to provide an endoscopic treatment option for patients with GERD. Because the endoscopic full-thickness Plicator enables rapid and easy placement of transmural sutures, comparable with surgical sutures, we used the Plicator device for endoscopic treatment or prevention of GI-wall defects.

OBJECTIVE

To describe the outcomes and complications of endoscopic full-thickness suturing during EMR and for the treatment of gastric-wall defects.

DESIGN

A report of 4 cases treated with the endoscopic full-thickness suturing between June 2006 and April 2007.

SETTING

A large tertiary-referral center.

PATIENTS

Four subjects received endoscopic full-thickness suturing. The subjects were women, with a mean age of 67 years.

INTERVENTIONS

Of the 4 subjects, 3 received endoscopic full-thickness suturing during or after an EMR. One subject received endoscopic full-thickness suturing for treatment of a fistula.

MAIN OUTCOME MEASUREMENTS

Primary outcome measurements were clinical procedural success and procedure-related adverse events.

RESULTS

The mean time for endoscopic full-thickness suturing was 15 minutes. In all cases, GI-wall patency was restored or ensured, and no procedure-related complications occurred. All subjects responded well to endoscopic full-thickness suturing.

LIMITATIONS

The resection of one GI stromal tumor was incomplete. Because of the Plicator's 60F distal-end diameter, endoscopic full-thickness suturing could only be performed with the patient under midazolam and propofol sedation. The durable Plicator suture might compromise the endoscopic follow-up after EMR.

CONCLUSIONS

The endoscopic full-thickness Plicator permits rapid and easy placement of transmural sutures and seems to be a safe and effective alternative to surgical intervention to restore GI-wall defects or to ensure GI-wall patency during EMR procedures.

Application of metal hemoclips for closure of endoscopic mucosal resection-induced ulcers of the stomach to prevent delayed bleeding

BACKGROUND

Bleeding is a major complication of endoscopic mucosal resection (EMR). This study investigated whether the use of metal hemoclips to close EMR-induced ulcers after gastric EMR was effective in preventing delayed bleeding.

METHODS

This single-center study retrospectively examined the records for 150 lesions of 140 consecutive patients (107 men and 33 women) with a mean age of 61 years (range, 38-81 years) who underwent EMR. For 60 patients, moderate to severe immediate bleeding occurred during the procedure, and the ulcers had been closed using metal hemoclips (clip group). In the remaining 90 cases, the immediate bleeding was absent or mild, and hemoclips were not used (nonclip group). Postprocedure bleeding (delayed bleeding) was analyzed.

RESULTS

Overall, delayed bleeding occurred with 14 (9.3%) of the 150 lesions. Delayed bleeding occurred less frequently in the clip group (2 of 60 lesions; 3.3%) than in the nonclip group (12 of 90 lesions; 13.3%; p = 0.04). Of the 60 clip group ulcers, 37 (62%) were completely closed, and none showed delayed bleeding. The median number of hemoclips used for ulcer closure was 10 (range, 4-22), and the median time for ulcer closure was 14 min (range, 4-40 min).

CONCLUSIONS

Prophylactic closure of gastric EMR-induced ulcers with hemoclips reduced delayed bleeding.

State of the art on endoscopic mucosal resection and endoscopic submucosal dissection

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) provide new alternatives for minimally invasive treatment of superficial gastrointestinal malignancies. Evidence suggests that these techniques can be performed safely and have comparable outcomes to surgery with less morbidity and better quality of life due to their tissue-sparing nature when compared with conventional surgery. Although the techniques and accessories have become standardized, there is room for improvement, and further research and development are required. Current challenges facing American gastroenterologists or endoscopic surgeons include access to training and lack of appropriate reimbursement for these heavy-weighted and technically demanding procedures. Nevertheless, EMR and ESD are here to stay and are only the first steps toward true radical endoluminal resection of GI malignancies.

Gastrostomy port assisted full-thickness gastric resection by using the peroral SurgASSIST introduced via an oroesophageal overtube in a porcine model

BACKGROUND

Intralumenal full-thickness gastric resection (FTGR) could be useful as a biopsy technique or in the management of gastric neoplasms. SurgASSIST is a cutting and stapling device delivered on a steerable shaft to which interchangeable stapling units are affixed.

OBJECTIVE

This feasibility study assessed the applicability of the SurgASSIST to perform intralumenal FTGR in a swine model.

DESIGN

Descriptive analysis; no statistical tests were applied.

SETTING

Animal laboratory.

METHODS

Four nonsurvival swine under general anesthesia were studied. An oroesophageal overtube was placed. A balloon trocar was inserted into the stomach under endoscopic guidance and served as a port for instruments and imaging. Under direct visualization, the SurgASSIST with a 55-mm straight-linear cutter and stapler unit (SLCS55) was advanced via the overtube into the stomach. We evaluated the safety and efficacy of overtube placement, SLCS55 insertion and maneuverability in the stomach, parallel versus perpendicular optics, and various tissue grasping devices to achieve FTGR.

RESULTS

Overtube insertion produced limited esophageal mucosal tears in 2 subjects and a severe tear in 1 subject. Maneuverability of the SLCS55 was limited. Endoscopic guidance for FTGR via both peroral (parallel) and per gastrostomy port (perpendicular) orientations was satisfactory. FTGR was successful in 2 of 4 subjects. Resected specimens measured 6.0 x 0.6 cm and 6.0 x 0.7 cm. There were no operative complications. In the remaining 2 subjects, the depth of resection was submucosa.

LIMITATIONS

Animal model.

CONCLUSIONS

Peroral intralumenal FTGR is feasible. A gastrostomy port facilitates triangulation for optics and tissue manipulation. Further refinements are needed to yield reliable results.