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Endoscopic Mucosal Resection
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Endoscopic Mucosal Resection

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  1. Endoscopic Mucosal Resection Dr. Howard Mertz Clinical Assistant Professor Vanderbilt University Saint Thomas HospitalNashville TN

  2. Acknowledgements • Wilson Cook support for this presentation • Olympus support for EMR training

  3. 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

  4. 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. 5 Layers of the GI tract by EUS EUS Histology Mucosa MM SubMuc MP Serosa

  6. 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

  7. Patient Selection and EUS: • 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

  8. T1, N0 Rectal Cancer Mass confined To mucosal layer Can be resected Transanal or by EMR

  9. Rectal Cancer T2,N0

  10. Nodule in Barretts Esophagus

  11. Nodule in Barretts Esophagus T1-2 N1

  12. Mucosal Lesion Evaluation sm> mp> 53 yo man with heartburn and nodule in Barretts epithelium. EUS: mucosal/submucosal lesion

  13. Submucosal Injection: • 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

  14. 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

  15. Submucosal Injection: • 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

  16. 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

  17. Techniques • Inject and snare • Inject, band and snare • Inject, suction cap, snare

  18. Devices • 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

  19. Lift and Snare

  20. Lift and Snare EMR

  21. Inject, Cap EMR, Snare

  22. Inject, Band, Snare

  23. Mucosal Lesion Evaluation sm> mp> 53 yo man with heartburn and nodule in Barretts epithelium. EUS: mucosal/submucosal lesion

  24. Endoscopic Mucosal Resection Submucosal Elevation Banding Snare Injection Resection Pathology: inflammatory polyp in Barretts

  25. Inject, Cap EMR, Snare

  26. 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

  27. Risk of Perforation • Highest • Duodenum • Colon, Esophagus • Stomach • Rectum • Lowest • Reported Rates 0.1-5%

  28. 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

  29. Bleeding Risk • 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%

  30. How to Minimize Bleeding • 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

  31. 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