Two-Endoscope Technique of Endoscopic Mucosal Resection for the Treatment of Gastric Intestinal Metaplasia

Abstract

Background and Aim: Gastric intestinal metaplasia (GIM) is precancerous with a worldwide prevalence of 25%. Eradicating Helicobacter pylori prevented about half of gastric cancers; failure to prevent the rest was attributed to GIM. GIM is irreversible and often extensive. There is no treatment. Existing endoscopic mucosal resection (EMR) is designed to treat early gastric cancer of usually <2 cm. A two‐endoscope technique of EMR for extensive GIM had been designed and successfully applied. Our aim is to describe the technique in detail. Two-endoscope technique of endoscopic mucosal resection: Patients with histologically confirmed moderate to severe GIM (operative link on GIM [OLGIM] classification) received the treatment in a daycare center. Chromoendoscopy with methylene blue was first performed to disclose and mark the GIM. Submucosal saline injections were used to lift the stained mucosa to form multiple safety cushions, which were then transformed into artificial polyps by suction and ligation, using a cap for ligation of esophageal varices. EMRs were then achieved by snare polypectomy. By rotating two gastroscopes, one designated to perform lift and snare and the other to perform suction and ligation, cycles of lift–ligate–snare were carried out until all stained mucosa was removed. Assessment chromoendoscopy with ≥seven biopsies was performed at 6 months. Results: A total of 227 EMRs were performed in 40 patients, with a median of 3.5 per patient. Bleeding was uncommon and minimal. Gastric perforation ascribable to loss of a safety cushion occurred in one patient. Chromoendoscopy at 6 months in 36 willing patients showed no recurrence of GIM. Conclusion: The two‐endoscope technique of EMR for GIM was essentially safe and effective, with no recurrence at 6 months. It could be performed by endoscopists with standard skills.