Complications of Endoscopic Mucosal Resection (EMR) in 122 Early Barrett's Cancers

Abstract

Background: Endoscopic mucosal resection has come to play a pivotal role in the staging and treatment of severe dysplasia (HGIN) and intramucosal cancer (IMC) in Barrett's esophagus (BE). Various techniques are available. The capped technique, which uses a transparent cap or variceal band ligator, is the most commonly practiced method. We present results and complications in a large consecutive series. Methods Between 2004 and 2006 all BE patients referred for endoscopic resection of HGN and IMC were included. Lesions were assessed endoscopically according to the Paris classification; the revised Vienna classification was used for histological assessment. Complications were defined according to international guidelines. Results: A total of 122 EMR's were performed in 102 patients (M/F 87/35, median age 66 yrs, range 26-91) with BE (27 short segment, 95 long-segment; mean length 4.6 cm, range 1-12 cm). Two resections were after a previous failed EMR in the referring center. Of the 122 lesions, 111 were flat, 5 ulcerated, 1 elevated and 5 polypoid, 85% of the lesions was focal with a diameter ranging from 0.5-4, 15% consisted of multi-focal or diffuse lesions. The large soft-cap (Olympus, Japan) technique with submucosal saline injection was used in 107 lesions, two patients were treated by means of a lift-and-cut EMR, and band-and-cut (Duetteâ; Cook, Ireland) without saline injection was performed in 13 patients. En-bloc resection was feasible in 38 (31%) lesions; all others were removed in a piecemeal fashion. Complete resection of the Barrett's segment was performed in 12 patients (10%). Five major complications occurred (4.1%): 2 perforations, 2 stenoses and 1 moderate post-procedural bleed. All complications were treated endoscopically. Both perforations were diagnosed during the procedure and were successfully treated with stenting, the stenoses occurred 3 and 5 weeks post-EMR and were successfully treated by single (1) and repeated Savary dilation (1), the EMR-related bleeding was treated with transfusion. Conclusions: EMR offers improved diagnosis and staging of early Barrett's cancer. In experienced hands, the procedure carries an acceptable complication risk. Most complications can be managed endoscopically. The capped technique enables en-bloc resection in a minority of cases.