Cap-assisted Endoscopic Mucosal Resection Research Articles

Tu1455 Cap-Assisted Endoscopic Mucosal Resection (C-EMR) Is Effective and Safe for Removal of Very Flat Right Colonic Polyps

Tu1455 Cap-Assisted Endoscopic Mucosal Resection (C-EMR) Is Effective and Safe for Removal of Very Flat Right Colonic Polyps

Which endoscopic treatment is the best for small rectal carcinoid tumors?

The incidence of rectal carcinoids is rising because of the widespread use of screening colonoscopy. Rectal carcinoids detected incidentally are usually in earlier stages at diagnosis. Rectal carcinoids estimated endoscopically as < 10 mm in diameter without atypical features and confined to the submucosal layer can be removed endoscopically. Here, we review the efficacy and safety of various endoscopic treatments for small rectal carcinoid tumors, including conventional polypectomy, endoscopic mucosal resection (EMR), cap-assisted EMR (or aspiration lumpectomy), endoscopic submucosal resection with ligating device, endoscopic submucosal dissection, and transanal endoscopic microsurgery. It is necessary to carefully choose an effective and safe primary resection method for complete histological resection.

Endoscopic Mucosal Resection for Esophageal Granular Cell Tumors

Purpose: Granular cell tumors (GCTs) are rare subepithelial lesions that may arise in the esophagus. Endoscopic mucosal resection (EMR) is used for the diagnosis, staging, and eradication of superficial esophageal neoplasms. EMR has been suggested as a treatment option for GCTs, but data is limited. Methods: A prospectively-collected pathology database was used to identify patients with esophageal GCT over the past 10 years at a university medical center. Information regarding demographic data, procedural findings, technical details of resection and adverse events was collected. Results: Fifteen patients (11 female, 4 male) with a mean age of 40 years (range, 21-64 years) were diagnosed with esophageal GCT. The majority of lesions (93%) were located in the distal esophagus. EMR was not performed in 4 patients (2 with muscularis propria involvement by EUS, 1 due to physician/patient decision, 1 GCT could not be re-identified). EMR was attempted by an experienced therapeutic endoscopist in the remaining 11 patients (Table 1). En bloc resection was achieved in 10/11 patients (91%) requiring only one session. Ligation-assisted EMR was performed in 8 patients (73%) and cap-assisted EMR was performed in the remaining 3 patients. A submucosal lift with normal saline was used in 7 cases (64%). Multiple esophageal GCTs were noted in two patients (case #5 had 4 lesions & case #8 had 2 lesions), all of which were completely excised. One lesion demonstrated a satisfactory submucosal lift; however, it was too large to be suctioned into a cap and further attempts to salvage resection failed to fully engage the lesion within the snare. This same patient later underwent operative resection of a gastric submucosal lesion and was diagnosed with a gastric GCT. There were no adverse events associated with ligation-assisted EMR. Two patients (18%) experienced acute bleeding after cap-assisted EMR. The patient in case #9 was treated with 4 cc of epinephrine with hemostasis achieved. The patient in case #10 had an ulcerated lesion that was treated with 8 cc of epinephrine after resection. This patient and was admitted to the hospital for overnight observation without further intervention. There were no cases of perforation.Table: [1871]Conclusion: Esophageal GCTs occur more commonly in the distal esophagus and appear to have a female predilection. EMR has a high rate of complete en bloc resection for esophageal GCTs. Lesion size is a limitation to EMR. While ligation-assisted EMR may reduce the risk of immediate bleeding, endoscopists performing EMR of esophageal GCTs should be prepared to manage the complications of bleeding. Disclosure: Dr. Chandrasekhara - None. Dr. Wilson - None. Dr. Ginsberg - None. Dr. Kochman - Spouse works for Merck.

A Comparative Study on Endoscopy Treatment in Rectal Carcinoid Tumors

To investigate the advantages and disadvantages of various endoscopic resection methods for rectal carcinoid tumors. A retrospective analysis of 3 types of endoscopic resection techniques for rectal carcinoid tumors was performed. The surgical time and the complication rate were compared between 30 patients who underwent conventional endoscopic mucosal resection (EMR), cap-assisted endoscopic mucosal resection (EMR-C), or endoscopic submucosal dissection (ESD). All rectal carcinoid tumors were under 1 cm and were treated in our center between January 2002 and January 2008. Ten patients underwent each surgical approach. All cases were pathologically diagnosed as rectal carcinoid tumors. One-time complete resection rates using the conventional EMR, EMR-C, and ESD were 80%, 100%, and 100%, respectively. The operation time ranged from 5 to 53 minutes for the conventional EMR group, from 4 to 7 minutes for the EMR-C group, and from 16 to 35 minutes for the ESD group. The average follow-up time for the 30 patients was 18.43 ± 9.76 months. There were no recurrent or metastatic cases. Endoscopic resection for rectal carcinoid tumors below 1 cm was safe. Considering the clinical efficacy, surgical time, and intraoperative complication rate, EMR-C may be the best endoscopic excision method.

Endoscopic Mucosal Resection: Not Your Father's Polypectomy Anymore

Endoscopic mucosal resection (EMR) is a continuously evolving technique that has revolutionized the diagnosis, staging, and treatment of superficial neoplasms throughout the digestive tract. As a minimally invasive technique, it offers an alternative to operative resection and mucosal ablation. For neoplasms limited to the mucosa, EMR compares equivalently with operative resection for R0 status (no residual neoplasia) and favorably for morbidity and mortality. In contrast with mucosal ablation, EMR delivers a more precise and predictable depth of tissue effect and, most important, provides the resected specimen for histopathologic analysis. EMR was pioneered in Eastern Asia as a technique for resection of early gastric cancers. Incrementally, the tools and techniques for EMR have evolved to be employed around the globe for eradication of superficial lesions throughout the esophagus, stomach, small bowel, and colon. Owing to improvements in endoscopic detection and recognition, more sessile, flat, depressed, and even subepithelial lesions are being identified for which endoscopic resection is being adopted. Moreover, the implementation of surveillance strategies for various gastrointestinal conditions, such as Barrett’s esophagus, has fostered image guided detection and eradication of premalignant and early malignant lesions, incorporating EMR for diagnosis, staging, and therapy. This review focuses on the techniques, applications, and limitations of EMR for lesions throughout the digestive tract.

Process of healing of mucosal defects in the esophagus after endoscopic mucosal resection: histological evaluation in a dog model

Resection of a large amount of the esophageal mucosa often causes esophageal ulcer and postoperative stricture. The aim of this study was to evaluate the process of healing of defects in the esophageal mucosa after endoscopic mucosal resection (EMR). Cap-assisted EMR was performed in the thoracic esophagus of six beagle dogs to prepare mucosal defects with a diameter ranging from 15 to 18 mm. The process of mucosal healing was assessed histologically immediately after EMR, and on postoperative day (POD) 2, 4, 7, 14, and 28. Immediately after EMR, a thin layer of the submucosa remained in the mucosal defect, and no damage to the muscularis propria was evident. Ulcer formation and inflammatory cell invasion were observed in the remaining submucosa on POD 2 and 4. Angiogenesis and collagen fiber hyperplasia were observed after POD 7. Complete epithelialization of the ulcer was observed on POD 28. In the muscularis propria, further destruction and atrophy were evident after POD 7. Fibrosis of the muscularis propria was observed on POD 28. In the esophageal wall after epithelial loss resulting from EMR, atrophy and fibrosis of the muscularis propria remain even after epithelialization.

Cap-assisted endoscopic mucosal resection of large polyps involving the ileocecal valve

Standard endoscopic mucosal resection (EMR) is limited with regard to lesions below or involving the ileocecal valve. We describe the treatment and outcomes when using cap-assisted EMR (EMR-C) to remove large laterally spreading tumors (LSTs) with ileal infiltration in seven patients (median age 74 years). Each LST (median size 40 mm) was successfully resected in one session (median procedure time 50 minutes). Intraprocedural and early bleeding occurred in two patients, and delayed hemorrhage in one. Circumferential resection of the ileum caused asymptomatic strictures in six patients, with regression during follow-up for five. We conclude that the novel EMR-C method is a potentially effective treatment for cecal LST involving the distal ileum. Serious complications such as perforation or symptomatic strictures of the ileocecal valve were not observed and any procedure-related bleeding was easily controlled.

Cap-Assisted Endoscopic Mucosal Resection for Colorectal Polyps

Cap-assisted endoscopic mucosal resection has been used to treat superficial esophageal and gastric cancers. Efficacy data in the colon are limited. The aim of the study was to evaluate the safety and efficacy of this technique in the treatment of sessile polyps and lateral spreading tumors in the colorectum. Two-hundred and fifty-five consecutive patients with sessile polyps or lateral spreading tumors >or=20 mm were treated between January 2000 and December 2007. A total of 146 sessile polyps and 136 lateral spreading tumors were treated with cap-assisted endoscopic mucosal resection. Complications occurred in 22 (8.6%) patients (5.5% in sessile polyps and 10.3% in lateral spreading tumors). Intraprocedural bleeding occurred in 21 (7%) of polypectomies (6% in sessile polyps and 10% in lateral spreading tumors); all were controlled endoscopically. Postcoagulation syndrome occurred in 1 patient with lateral spreading tumor. No perforation occurred. Invasive adenocarcinoma was found in 35 patients, of whom 15 underwent surgery. Endoscopic follow-up in 200 patients with 216 adenomas for a median of 12.1 months showed recurrence in 8 (4%) who were treated with resection and/or ablation. Cap-assisted endoscopic mucosal resection is an effective treatment for sessile polyps and lateral spreading tumors. A disadvantage of the technique is that the resection is piecemeal. Close surveillance provides the opportunity for additional tissue ablation, when required, to achieve complete lesion removal.

W1438: CAP-Assisted Endoscopic Mucosal Resection of Flat Colonic Lesions: How Does It Compare to Inject-and-Cut Technique?

W1438: CAP-Assisted Endoscopic Mucosal Resection of Flat Colonic Lesions: How Does It Compare to Inject-and-Cut Technique?

SLOW GROWING FLAT‐TYPE PRIMARY MALIGNANT MELANOMA OF THE ESOPHAGUS TREATED WITH CAP‐ASSISTED EMR

We report a rare case of flat-type primary malignant melanoma of the esophagus treated with endoscopic mucosal resection (EMR). A 64-year-old woman was referred for examination of a small pigmented lesion located in the mid esophagus. On endoscopy, the lesion exhibited almost no change in size over the year. Cap-assisted EMR was performed en bloc. The histopathological findings showed atypical melanocyte proliferation in the basal layer, spindle cells, and epithelioid cell proliferation with nuclear enlargement and a few mitotic figures. Histopathological examination confirmed the diagnosis of primary malignant melanoma. Immunostaining for S-100 protein and HMB-45 antibody were positive, and the Ki-67 index was low. The patient was discharged without additional surgical resection and/or chemotherapy. The patient had no symptoms and no signs of recurrence 20 months after EMR. There has been no report on a slow growing esophageal melanoma. It is difficult to estimate the malignant behavior of this case.

Endoscopic Closure of Cervical Esophageal Perforation Caused By Traumatic Insertion of a Mucosectomy Cap

Cap-assisted endoscopic mucosal resection enables nonsurgical removal of superficial esophageal lesions. Perforation at the resection site is a rare but known complication of this technique. We report a case in which traumatic insertion of the mucosectomy cap led to perforation of the cervical esophagus. This complication has not been previously reported. The perforation was successfully closed by the endoscopic placement of clips.

Endoscopic Ultrasonography (EUS) and Endoscopic Mucosal Resection (EMR) for Staging and Treatment of High-Grade Dysplasia (HGD) and Early Adenocarcinoma (EAC) in Barrett's Esophagus (BE)

Aim: Endoscopic therapy can be curative for BE and HGD (Tis) or EAC confined to the mucosa (T1m). The risk of lymph node metastasis increases with the depth of mucosal invasion, and rises rapidly with submucosal invasion (T1sm). EUS has provided the highest accuracy for clinical staging of depth of invasion, but remains imperfect. We tested a staging strategy of an initial EUS, followed by EMR in patients with ≤T1m on EUS. Methods: We staged patients with HGD or EAC with high-frequency EUS (20 MHz). Patients with EUS stage of ≥T1sm were referred to surgery. Patients with EUS stage ≤T1m had cap-assisted EMR of focal lesions in long-segment BE or of all short segment BE. EMR specimens were evaluated by histology: m1 = tumor above the basement membrane (HGD); m2 = tumor invading the lamina propria; m3 = tumor invading the muscularis mucosae; sm = tumor invading the submucosa. Results: A total of 50 patients (40 M, 10 F), mean age 70 years (range 36-87 years) with HGD and possible EAC in BE were evaluated with EUS. In 8 patients, EUS indicated ≥T1sm. EUS was accurate compared to surgical pathology in 7/8 cases, but over-staged 1 patient with T1m disease. EMR was carried out in the remaining 42 patients (20 focal lesions, 22 short segment BE). EMR staging results compared with initial endoscopic biopsy diagnosis are shown in the table below. EMR was carried out as an outpatient procedure without serious complication. Subsequent treatment was based on EMR results and clinical status. In the 22 patients with m1 (HGD) on EMR, 1 had esophagectomy, and 21 had endoscopic follow-up, including 6 who received additional endoscopic therapy (EMR, photodynamic therapy, or argon plasma coagulation). None of the 21 developed metastatic cancer over a mean of 15.4 ± 9.0 months. In the 20 patients with EAC on EMR, 6 had esophagectomy, including 5/6 with sm invasion. In 12/14 patients, additional endoscopic therapy was carried out, and 1 patient received combined radiation and chemotherapy. None of the 14 developed metastatic cancer over a mean of 19.7 ± 8.9 months. Conclusions: Staging patients with HGD and EAC in BE can be performed accurately with EUS followed by EMR. Invasion of the deep mucosa and the submucosa can be definitively established. In medium-term follow-up, endoscopic therapy has been successful in patients with HGD and cancer limited to the mucosa.

Hello, Mr. Clips—could you chip in please?

Hello, Mr. Clips—could you chip in please?

Combo cap takes a big bite, yet a smoothie to swallow

Combo cap takes a big bite, yet a smoothie to swallow

Circumferential endoscopic mucosal resection in the swine esophagus assisted by a cap attachment

Background: The feasibility and safety of piecemeal, circumferential endoscopic mucosal resection of the distal esophagus are unknown. This study assessed this procedure in a porcine model. Methods: Different techniques of endoscopic mucosal resection were tested in Phase I of the study in two animals. During Phase II, 6 pigs underwent piecemeal cap-assisted EMR of the distal esophagus. The mucosa of one half of the circumference of the distal 5 cm of the esophagus was resected. After complete endoscopic re-epithelization, endoscopic mucosal resection was performed on the remaining unresected hemi-circumference. Healing was promoted by daily administration of lansoprazole and documented by weekly endoscopy. Observations: In Phase I, one perforation occurred during initial testing of cap-assisted endoscopic mucosal resection. Subsequent cap-assisted endoscopic mucosal resection led to homogenous and uniform piecemeal resection of mucosa. In Phase II, circumferential cap-assisted endoscopic mucosal resection was performed in 6 pigs without perforation or major bleeding. Complete endoscopic re-epithelization occurred over a mean of 3.6 weeks (range: 3-5). Strictures developed in 3 animals. Conclusions: Piecemeal circumferential cap-assisted endoscopic mucosal resection is safe and feasible in the normal swine esophagus. Proper technique for cap-assisted piecemeal endoscopic mucosal resection is necessary to minimize the risk of perforation. Procedural complications include esophageal stricture formation.

Cap-assisted endoscopic mucosal resection for neoplastic lesions of the gastrointestinal tract

Cap-assisted endoscopic mucosal resection for neoplastic lesions of the gastrointestinal tract