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
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
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
5 Layers of the GI tract by EUS
EUS
Histology
Mucosa
MM
SubMuc
MP
Serosa
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
Patient Selection and EUS:
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•
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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
T1, N0 Rectal Cancer
Mass confined
To mucosal layer
Can be resected
Transanal or
by EMR
Rectal Cancer T2,N0
Nodule in Barretts Esophagus
Nodule in Barretts Esophagus
T1-2
N1
Mucosal Lesion Evaluation
sm>
mp>
53 yo man with heartburn and nodule in
Barretts epithelium.
EUS: mucosal/submucosal lesion
Submucosal Injection:
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•
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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
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
Submucosal Injection:
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•
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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
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
Techniques
• Inject and snare
• Inject, band and snare
• Inject, suction cap, snare
Devices
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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
Lift and Snare
Lift and Snare EMR
Inject, Cap EMR, Snare
Inject, Band, Snare
Mucosal Lesion Evaluation
sm>
mp>
53 yo man with heartburn and nodule in
Barretts epithelium.
EUS: mucosal/submucosal lesion
Endoscopic Mucosal Resection
Submucosal Elevation
Injection
Banding
Snare
Resection
Pathology: inflammatory polyp in Barretts
Inject, Cap
EMR, Snare
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
Risk of Perforation
• Highest
– Duodenum
– Colon, Esophagus
–
Stomach
–
Rectum
•
Lowest
• Reported Rates 0.1-5%
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
Bleeding Risk
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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%
How to Minimize Bleeding
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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
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