Complete Endoscopic Mucosal Resection Research Articles

OGC SO19 - Management and outcomes for Barrett’s oesophagus with dysplasia in a tertiary centre

Abstract Background Barrett’s oesophagus is a premalignant condition. Development of high-grade dysplasia (HGD) formerly was an indication for oesophagectomy, but endoscopic treatment (ET) is now recommended as first-line therapy: radiofrequency ablation (RFA) or endoscopic mucosal resection (EMR). Oesophagectomy is only considered for cases where ET was unsuccessful. Previous review of our institution’s outcomes between 2014 and 2017 showed a 54% complete EMR excision rate and 20% salvage oesophagectomy (n=25). Since then, RFA has been utilised in our institution. We aimed to review our recent data to assess current outcomes. Method Retrospective analysis was performed of patients identified via registration at the Hull University Hospital Trust oesophagogastric MDT between March 2017 and December 2023. Inclusion criteria was confirmed histology of HGD on 2 occasions by 2 specialist pathologists, 6 weeks apart. EMR was performed for focal oesophageal lesions and non-nodular segments were treated by RFA. Patients were included once they had at least one surveillance endoscopy and 6 months had passed following treatment. Patients who were either unfit for ET and managed medically (n=6), and those who were subsequently proven to have more advanced disease and treated surgically (n=4) were excluded. Results 35 patients were identified: 20 underwent EMR, 15 RFA. 55% of EMR patients had successful excision, 9 required additional RFA for residual low-grade dysplasia (LGD). 66% RFA patients had successful ablation. 3 patients required further EMR for residual LGD. Overall 82% had successful ET with no HGD on surveillance. 5 patients had persistent HGD and 1 T1b disease: 4 underwent oesophagectomy, 2 managed oncologically. Barrett’s tended towards being longer in patients where ET failed to eradicate HGD (median 6cm vs 3cm MWU p=0.07). No patient in the series died because of disease-related pathology. 1 patient developed stricture post-RFA requiring dilatation. Conclusion ET for HGD is effective with a high rate of successful treatment. It can be used as a single or dual modality. Salvage oesophagectomy rates are lower than previously reported (8% vs 20%) and complications are low (3% stricture rate). Longer segment Barrett’s may be less likely be responsive to ET, although not reaching significance in our series. ET should continue to be offered as the first-line treatment for oesophageal HGD.

Does completing advanced endoscopy fellowship improve outcomes after endoscopic mucosal resection?

It was reported that about 60% of the physicians in the USA believed that their Gastroenterology fellowship poorly prepared them for large polyp resection. The aim of this study was to compare endoscopic mucosal resection (EMR) efficacy and complication rates between skilled general gastroenterologists who perform high volume of EMR and advanced endoscopists. We identified 140 patients with documented large colonic polyps treated by 4 providers using EMR technique at Carilion Clinic, in Roanoke, Virginia, USA between 01/01/2014-12/31/2017, with follow-up through 10-2018. Information on demographics, clinical and pathological features of high-risk polyps (i.e., size, histology, site, and degree of dysplasia), timing of surveillance endoscopies, tools used during resection, and skills of performing endoscopist's were extracted. The cumulative risks of polyp recurrence after first resection using EMR technique were estimated using Kaplan-Meier curves. One hundred and forty patients were identified (mean age, 64.1±11.2 years; 47.1% males). Fifty-five polyps (39.3%) were removed by 2 skilled gastroenterologists and 85 (60.7%) were removed by advanced endoscopists. Most of the polyps resected were located in the right colon (63.6%) and roughly half of the polyps were removed in piecemeal fashion. At follow-up endoscopy, the advanced endoscopy group had lower polyp recurrence rates. The median recurrence after polypectomy was significantly different between the groups (0.88 and 1.03 years for skilled gastroenterologists who did not complete and completed EMR hands-on workshops; respectively vs. 3.99 years for the advanced endoscopist who did not complete EMR hands-on workshop, P=0.03). There is a need for additional EMR training since polyp recurrence was significantly different between the groups despite high rates of piecemeal resection in the advanced endoscopy groups.

Clinical characteristics of non-ampullary duodenal polyps in the elderly and the outcomes of endoscopic mucosal resection.

At present, there are no reports on non-ampullary polyps of the duodenum (NAPDs) in the elderly. The aim of this study was to analyze the clinicopathological features of NAPDs in elderly and non-elderly patients to explore the efficacy and safety of endoscopic mucosal resection (EMR) of NAPDs in the elderly.A total of 110 patients underwent EMR of NAPDs between April 2016 and December 2019. The shape, location, size, postoperative complications, and histopathological types of NAPDs were compared between the elderly group (n = 44) and the non-elderly group (n = 66).Sessile type was the most common form of NAPD in both groups. In the elderly group, the average size of NAPDs was 12.6 ± 3.9 mm. In the non-elderly group, NAPDs had an average size of 10.1 ± 5.8 mm. Complete EMR was performed in both groups. The postoperative complications of EMR did not significantly differ between the 2 groups. Postoperative pathological examination showed that tubular villous adenomas were more common in the elderly group than in the non-elderly group (P = .005), while tubular adenomas were more common in the non-elderly group than in the elderly group (P = .007). Of the 110 patients, 99 completed postoperative follow-up (median follow-up duration, 20.93 months). There were no residual or recurrent lesions.EMR is safe and effective for the treatment of NAPDs in elderly patients.

S2987 Arteriovenous Malformation of Stomach: A Rare Case of Symptomatic Non-Bleeding Gastric Subepithelial Lesion

INTRODUCTION: Gastric arteriovenous malformations (AVM) are rarely been reported. They are uncommon cause of upper gastrointestinal bleeding and abdominal pain. Here we report an unusual case of a middle-aged female who presented to us with intermittent epigastric discomfort and was diagnosed as a case of gastric AVM also mimicking dieulafoy lesion. CASE DESCRIPTION/METHODS: A 50-year-old female with a past medical history of hypertension, hyperlipidaemia, GERD, and depression was admitted to the hospital with intermittent epigastric discomfort, bloating, and decreased appetite for 4 months. There was also a history of 10 lbs of weight loss. There was no history of dysphagia or odynophagia. Physical examination was within normal limits and laboratory investigations were unremarkable. CT abdomen was performed due to concerns of weight loss which revealed a 1.5 cm lesion in the gastric fundus. The patient underwent an EGD which showed 1.5 cm subepithelial lesion with smooth overlying surface present in the gastric fundus with no ulcerations. Differential diagnoses included GIST, leiomyoma, and carcinoid. Endoscopic ultrasound was performed which showed the presence of 11.8 mm × 10.1 mm hypoechoic lesion which appears to be arising from the submucosal layer with mild internal vascularity. The muscularis propria layer appeared intact. A complete endoscopic mucosal resection was performed. Pathology was sent and showed benign gastric mucosa with proliferation of blood vessels in the submucosa. Although the vessels were prominent, but they were not large or tortuous as seen in Dieulafoy's lesion. Patient was later discharged on oral proton pump inhibitor for 4 weeks. On follow up clinic visit she remained asymptomatic and improved clinically. DISCUSSION: Gastric AVMs represent 1.4% of all intestinal AVMs. It is a congenital lesion with direct connection between its arterial and venous component. Gastric AVMs are diagnosed on endoscopy and treatment mostly involves endoscopic removal or surgery. The gastric AVM in our case mimicked a dieulafoy lesion. However the pathology confirmed it to be an gastric AVM.Figure 1.: EGD showed a 1.5 cm subepithelial lesion with smooth overlying surface present in the gastric fundus with no ulcerations.Figure 2.: EUS showing a 11.8 mm × 10.1 mm hypoechoic sub-epithelial lesion which appears to be arising from submucosa with mild internal vascularity.Figure 3.: Histopathology showed benign gastric mucosa with proliferation of blood vessels in the submucosa. Although the vessels are prominent, they are not large or tortuous as seen in Dieulafoy's lesion.

Art in Endoscopy: "Prehistoric cave art".

This image was observed after a macroscopically complete endoscopic mucosal resection of a rectal adenoma. Before resection the submucosa was injected with indigo carmine, resulting in a beautiful blue background with the unaffected red vessels looking remarkably like a prehistoric cave painting.

Complete endoscopic mucosal resection of malignant colonic sessile polyps and clinical outcome of 51 cases

Complete endoscopic mucosal resection of malignant colonic sessile polyps and clinical outcome of 51 cases

Complete endoscopic mucosal resection of malignant colonic sessile polyps and clinical outcome of 51 cases.

BackgroundMeta-analyses and guidelines recommend that deep submucosal invasion (>1 mm) of malignant sessile colonic polyps is an important risk factor for lymph node metastasis. However, existing data are based on small retrospective studies with marked heterogeneity. We herein aimed to investigate the long-term outcomes of patients who underwent complete endoscopic mucosal resection (EMR) of malignant colonic sessile polyps invading the submucosal layer.MethodsEndoscopy records for the period 2000-2016 were reviewed retrospectively. All enrolled patients exhibited an endoscopically resected malignant colonic sessile polyp. All patients were advised to undergo surgery, but some opted for conservative treatment and endoscopic follow up.ResultsFifty-one patients with confirmed infiltrative submucosal adenocarcinoma in sessile colonic polyps that had undergone complete EMR were detected. A total of 32 (62.7%) patients opted for surgery after EMR and 19 (37.3%) chose endoscopic follow up. In 44 (86.3%) patients the submucosal invasion was >1 mm. Residual malignant disease was identified in the surgical pathological specimen of only 1 patient. During a median follow up of 23.41 months (interquartile range 33.45, range 1.84-144.92), no local recurrences or lymph node metastasis were identified. Forty-nine patients are alive without evidence of disease and 2 died of other causes (without evidence of local or metastatic disease at last follow up).ConclusionOur data suggest that complete EMR of cancerous colonic sessile polyps, even in cases of submucosal invasion >1 mm carries a low risk of recurrence and therefore may need further evaluation as an alternative strategy to surgical resection.

Efficacy, Durability, and Safety of Complete Endoscopic Mucosal Resection of Barrett Esophagus: A Systematic Review and Meta-Analysis.

To report the rate of eradication and recurrence of both neoplasia and intestinal mucosa and the rate of adverse events for complete endoscopic resection (CER) of Barrett esophagus (BE). There is limited composite data on the clinical efficacy of CER of BE with high-grade dysplasia or neoplasia. We performed a systematic review and meta-analysis of cohort studies that reported the clinical outcome of patients with BE who underwent CER and had at least 15-month follow-up after the time of elimination of BE. Main outcome of interests were pooled estimated rates of complete eradication of intestinal metaplasia and neoplasia, recurrence of intestinal metaplasia and neoplasia, and incidence of esophageal stricture, bleeding, and perforation. We identified 8 studies reporting on 676 patients (high-grade dysplasia 54%) that met our criteria. Pooled estimated rates of complete eradication of intestinal metaplasia and complete eradication of intestinal neoplasia were 85.0% [95% confidence interval (CI), 79.4%-89.2%] and 96.6% (95% CI, 94.0%-98.1%), respectively, and rates of recurrence of intestinal metaplasia and recurrence of intestinal neoplasia were 15.7% (95% CI, 8.0%-28.4%) and 5.8% (95% CI, 3.9%-8.6%), respectively. Estimated incidences of adverse events were stricture 37.4 (95% CI, 24.4%-52.6%), bleeding 7.9% (95% CI, 4.4%-13.8%) and perforation 2.3% (95% CI, 1.3%-4.1%). CER achieves an 85% complete eradication rate of BE with recurrent rate of neoplasia of 6%. Estimated rate of postprocedural stricture was 37.4%. On the basis of this high rate of adverse events and significant heterogeneity in the studies included, the present meta-analysis cannot endorse CER as sole therapy for BE.

Analysis of the Pathological Examination Results of 100 Colon Polyps Cases after EMR or ESD Operation

Aim: To study the characteristics of EMR (endoscopic mucosal resection) or ESD (endoscopic submucosal dissection) postoperative pathological examination of colonic polyps in different age groups, and the difference of pathological examination after EMR or ESD operation. Methods: A retrospective analysis was made of the EMR or ESD postoperative pathological data of 100 cases of colonic polyps patients in the Jingzhou Central Hospital digestive internal medicine. The time is from March 2016 to March 2018. Results: In 100 cases of EMR or ESD operation, there are 65 cases of young and middle-aged group. Pathological examination results include: 34 cases of adenomatous polyp, 18 cases of inflammatory polyp, 11 cases of benign tumors, 1 case of malignant tumor, 1 case of hyperplastic polyp. There are 35 cases of elderly group. Pathological examination results include: 27 cases of adenomatous polyp, 2 cases of inflammatory polyp, 2 cases of benign tumors, 4 cases of malignant tumor. 71 cases of complete EMR operation include: 51 cases of adenomatous polyp, 17 cases of inflammatory polyp, 3 cases of benign tumors; 29 cases of complete ESD operation include: 10 cases of adenomatous polyp, 3 cases of inflammatory polyp, 10 cases of benign tumors, 5 cases of malignant tumor, 1 case of hyperplastic polyp. Conclusion: For the pathological examination results after EMR or ESD operation, the proportion of inflammatory polyps in the young and middle-aged group was greater than that in the elderly group. The proportion of adenomatous polyps in the elderly group was larger than that in the young and middle-aged group. The proportion of adenomatous polyps in EMR was greater than that of ESD. The proportion of benign tumors and malignant tumors in ESD was greater than that of EMR. The difference has statistical significance.

Recurrence of intestinal metaplasia and early neoplasia after endoscopic eradication therapy for Barrett's esophagus: a systematic review and meta-analysis.

Background Conflicting data exist with regard to recurrence rates of intestinal metaplasia (IM) and dysplasia after achieving complete eradication of intestinal metaplasia (CE-IM) in Barrett’s esophagus (BE) patients. Aim (i) To determine the incidence of recurrent IM and dysplasia achieving CE-IM and (ii) to compare recurrence rates between treatment modalities [radiofrequency ablation (RFA) with or without endoscopic mucosal resection (EMR) vs stepwise complete EMR (SRER)]. Methods A systematic search was performed for studies reporting on outcomes and estimates of recurrence rates after achieving CE-IM. Pooled incidence [per 100-patient-years (PY)] and risk ratios with 95 %CI were obtained. Heterogeneity was measured using the I 2 statistic. Subgroup analyses, decided a priori, were performed to explore heterogeneity in results. Results A total of 39 studies were identified (25-RFA, 13-SRER, and 2 combined). The pooled incidence of any recurrence was 7.5 (95 %CI 6.1 – 9.0)/100 PY with a pooled incidence of IM recurrence rate of 4.8 (95 %CI 3.8 – 5.9)/100 PY, and dysplasia recurrence rate of 2.0 (95 %CI 1.5 – 2.5)/100 PY. Compared to the SRER group, the RFA group had significantly higher overall [8.6 (6.7 – 10.5)/100 PY vs. 5.1 (3.1 – 7)/100 PY, P = 0.01] and IM recurrence rates [5.8 (4.3 – 7.3)/100 PY vs. 3.1 (1.7 – 4)/100 PY, P < 0.01] with no difference in recurrence rates of dysplasia. Significant heterogeneity between studies was identified. The majority of recurrences were amenable to repeat endoscopic eradication therapy (EET). Conclusion The results of this study demonstrate that the incidence rates of overall, IM, and dysplasia recurrence rates post-EET are not inconsiderable and reinforce the importance of close surveillance after achieving CE-IM.

Efficacy of viscous budesonide slurry for prevention of esophageal stricture formation after complete endoscopic mucosal resection of short-segment Barrett's neoplasia.

Complete endoscopic resection (CER) of short-segment Barrett's esophagus with high grade dysplasia (HGD) and early esophageal adenocarcinoma (EEA) is a precise staging tool and achieves durable disease control. The major drawback is development of post-endoscopic resection esophageal stricture (PERES). No effective therapy to prevent PERES has been described. Viscous budesonide slurry (VBS) may have a role in the prevention of PERES by suppressing the post-CER inflammatory process. The study aim was to evaluate the efficacy of VBS for the prevention of PERES. Prospective data were collected on patients referred for CER of HGD or EEA. After January 2012, patients routinely received VBS (two 0.5-mg/2-mL budesonide respules mixed with sucralose) twice daily for 6 weeks following each stage of the CER schedule. All patients received high dose proton pump inhibitor therapy for the duration of CER and the following 3 months. Patients had no other intervention to prevent PERES. A validated dysphagia score was used (0 - 4, no dysphagia to aphagia). Endoscopic dilation was performed for dysphagia. Patients receiving VBS were compared with historical controls. The primary endpoint was the need for dilation. Between January 2008 and January 2015, 104 of 116 eligible patients completed CER. The VBS group (n = 29) and non-VBS group (n = 75) had similar patient, disease, and procedural characteristics. Dilations were needed in 13.8 % vs. 37.3 % (P = 0.03), with a median of one vs. two procedures (P = 0.01), and median dysphagia score during CER of 0 vs. 1 (P = 0.02) in the VBS and non-VBS groups, respectively. No VBS-related adverse events were noted. In this pilot study VBS significantly reduced PERES and shortened the dilation program after CER.

PTU-039 Outcome of endoscopic mucosal resection of 424 large sessile colonic polyps (≥20 mm) over a 9 year period: a single centre experience and analysis of change with time

Introduction Endoscopic mucosal resection (EMR) is now standard for resection of large sessile colonic polyps. We aimed to assess the clinical outcome of colonic EMR of polyps ≥2 cm size at a University Hospital and changes over a 9 year period. Method Data was collected for all sessile colonic polyps ≥20 mm removed by EMR between 2006 and 2014 by 3 endoscopists. Patient demographics, resection technique, completeness of initial resection, recurrence rate at first surveillance (SC1), polyp eradication at 2 nd surveillance after at least 1 year (SC2) and complication rates were analysed. Results 564 patients were assessed for EMR, 424 completed EMRs (BCSP138, Symptomatic286). Of the 140 not having complete EMR, 65 with no attempt at EMR were referred for surgery (cancer 31, technical difficulty 34).32 EMR was attempted but abandoned; all were referred for surgery (cancer 18, benign polyp 14). Finally, 43 had no intervention (13 declined, 22 non-adenomatous polyps, 8 moved away). Mean age 68.7 years (range 25–93), male 226 (53%), female 198 (47%). Mean polyp size 33 mm (median 30 mm). Polyp site right colon 27%, transverse 5%, left 68% (rectum 58%, sigmoid 4%, descending 6%). Piecemeal EMR 381 (90%),’en bloc’43 (10%). Those who have undergone surveillance, recurrence was found in 56/284 (19.7%) at initial SC1 (mean 7 month; range 2–36) and was endoscopically treated in 53/56 (94.6%); 3/56 (5.4%) referred for surgical resection (2 cancer, 1 non lifting). Complete eradication after one year SC2 (mean 16 months; range 5–51) 211/234 (90.2%) with recurrence in 23 (9.8%)–22/23 endoscopically resected. Overall complication rate 17/424 (4%):caecal perforation 1/424 (0.2%) and post polypectomy pain syndrome 14 (3.3%) all treated conservatively; delayed bleeding 2 (0.5%) required endoscopic therapy to achieve haemostasis. No deaths. For each 3 year period (2006–8, 2009–11, 2012–14), there was reduction in number of polyps not treated endoscopically or requiring surgery (overall decrease of 15.7%), incomplete EMR referred for surgical resection (overall decrease of 2.3%) and recurrence at first SC1(overall decrease 16.3%). There were increases in numbers of EMRs performed (overall increase 26%), mean polyp size resected (+7 mm), level 3 and 4 polypectomies (3.7 and 7%) and complete eradication rate at SC1 (16.3%). Conclusion This EMR series of 424 sessile colonic polyps >2 cm was performed by 3 operators over a 9 year period; 19.7% had recurrence at initial surveillance, most managed endoscopically, with eradication rate at 1 year of over 90% (22/23 one year recurrences treated endoscopically). Time trends showed progressive reduction in recurrence and a trend for larger, more complex polyps to be resected endoscopically, with a corresponding drop in surgical management, demonstrating improvement in outcome with time. Disclosure of interest None Declared.

Complete Endoscopic Mucosal Resection Is Effective and Durable Treatment for Barrett's-Associated Neoplasia

Barrett's esophagus (BE) with high-grade dysplasia (HGD) or intramucosal carcinoma (IMC) is treated by complete eradication of areas of BE by endoscopic mucosal resection (EMR). By using this approach, histologic analysis also can be performed. We investigated the effectiveness, safety, and durability of this approach, as well as its use in diagnosis after a single referral. We collected data from 107 patients who were referred to the Center for Endoscopic Research and Therapeutics at the University of Chicago for BE (mean length, 3.6 cm) with suspected HGD or IMC, from August 2003 through December 2012. All patients underwent EMR and were followed up through January 2014 (mean follow-up time, 40.6 mo). The primary outcome was treatment efficacy (complete eradication of BE and associated neoplasia); secondary outcomes included safety, durability, and accuracy of diagnosis. BE was eradicated completely by EMR in 80.4% (86 of 107) of patients based on intention-to-treat analysis, and in 98.8% (79 of 80) of patients based on per-protocol analysis. The diagnosis was changed for 25% of patients after EMR, including 4 cases that initially were diagnosed as HGD by biopsy analysis and subsequently were found to have evidence of submucosal invasion when EMR specimens were assessed. Strictures and symptomatic dysphagia developed in 41.1% and 37.3% of patients, respectively, with an average of 2.3 dilations required. Perforations occurred in 2 patients after EMR and in 1 patient after dilation. HGD and IMC recurred in 1 patient each; both were treated successfully with EMR. Based on pathology analysis of the most recently collected specimens, 71.6% of patients (53 of 74) were in complete remission from intestinal metaplasia and 100% were in complete remission from HGD (74 of 74) or cancer (74 of 74). For patients with BE with HGD or neoplasia, complete EMR is an effective and durable treatment and is a relatively safe technique. Specimens collected by EMR also can be analyzed histologically to aid in diagnosis. The common complication of EMR is esophageal stricture, which can be addressed with endoscopic dilation.

Tu1457 Improving Complete Endoscopic Mucosal Resection of Large Sessile Colorectal Neoplasia: a Randomized Trial Comparing Snares and Injectate

Endoscopic mucosal resection (EMR) is a method for removing sessile or flat neoplasms confined to the superficial layers of the gastrointestinal tract. Injection of a saline or viscous agent into the submucosa prior to EMR is necessary. However repeated injections with exchange of needle accessories is time consuming. Furthermore, residual lesion rates can be as high as 46%, primarily due to piecemeal resection. The goal of this study was to compare two devices: a combined needle and snare unit (iSnare® system - hexagonal snare, US Endoscopy) versus an oval Snaremaster with spiral wire (Snaremaster, Olympus),and secondarily to compare non-viscous vs.

Predictors of Complete Endoscopic Mucosal Resection of Flat and Depressed Gastrointestinal Neoplasia of the Colon

We evaluated risk factors for residual neoplasia on first follow-up endoscopy after colonic endoscopic mucosal resections (EMRs). This retrospective study in a high-volume EMR tertiary-referral center examined EMRs on 423 colonic lesions in 313 patients. Residual neoplasia at first follow-up endoscopy was present following 12% of colonic EMRs. Single-variable analysis showed evidence of an increased risk of residual neoplasia for larger polyps, polyps without a lifting sign, and polyps removed piecemeal. In multivariable analysis, only use of the piecemeal method was independently associated with residual neoplasia. Additional procedures are needed to complete resection in more than 1 in 10 colonic EMRs. Residual neoplasia occurs more often with piecemeal resection. Close surveillance after EMR and the use of newer methods to further reduce residual neoplasia are needed.

Combined use of endoscopic ultrasound and confocal endomicroscopy for complete EMR of early gastric neoplasia

Endoscopic mucosal resection (EMR) is an alternative to surgery for removal of superficial gastric neoplastic lesions.

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.

OC-026 Joint endoscopic and laparoscopic approach as a salvage procedure for very large rectal lesions

Introduction Endoscopic mucosal resection (EMR) is an excellent technique for removing large lesions. It can also be used as an adjunct to surgery. Be describe a case where EMR was used to partially remove a large rectal adenoma, enabling a less radical surgical approach to be taken. Methods A 55-year-old woman with a previous history of an anterior resection for a sigmoid tumour was referred with a large 18-cm LST-G rectal adenoma, crossing the dentate line and involving the surgical anastomosis. It had been suggested that the only treatment option was an AP resection with permanent colostomy. On assessment of the lesion it was clear that a complete endoscopic resection was not possible due to the scar tissue from the previous surgery. However, it was decided that it would be possible to clear a 10-cm cuff to enable a low resection with primary anastomosis to be performed. Results A 10-cm cuff was cleared by piecemeal resection of the lesion using a conventional EMR technique. The patient was followed up after 8 weeks where a joint assessment by gastroenterologist and rectal surgeon was performed. It was felt that a sufficient margin had been created for a resection and primary anastomosis to be performed in. She subsequently underwent a successful laparoscopic surgical resection. Conclusion When a complete EMR is not viable it is important not to dismiss the potential benefit which can be gained by a combined endoscopic and laparoscopic surgical approach. This case illustrates how a permanent colostomy can be avoided in patients with low rectal lesions associated with scarring precluding a total endoscopic mucosal resection.

Trimodal imaging-assisted endoscopic mucosal resection of early Barrett’s neoplasia

Chromoendoscopy is traditionally used to identify inconspicuous Barrett's neoplasia and mark the boundaries before endoscopic mucosal resection (EMR). Trimodal imaging endoscopy is useful in identifying early neoplasia in Barrett's esophagus. The purpose of this study was to determine the efficacy (lateral and deep margin clearance) of trimodal imaging endoscopy-assisted EMR in early Barrett's neoplasia in a tertiary referral setting. The entire Barrett's segment was visualized by high-resolution endoscopy followed by autofluorescence imaging, and suspicious areas were identified. Narrow band imaging and magnification was used to confirm the suspicious areas. The outer boundary of the lesion was then marked using the tip of a snare diathermy and EMR was performed using multiband mucosectomy technique by a single operator (KR). Sixteen patients were included: 13 patients had high-grade intraepithelial neoplasia (HGIN); 3 patients had intramucosal carcinoma (IMC); (8 males, median age, 69.5 (range, 50-77) years with Barrett's esophagus (interquartile range (IQR), 2-5 cm; median length, 3 cm). All lesions were successfully identified, using trimodal imaging endoscopy. Overall EMR was complete in 14 of 16 (81.2%) patients with early Barrett's neoplasia. Four of 16 patients (18%; all with pre-EMR HGIN) were considered to have incomplete EMR (deep margins involved), but operative histology showed only Barrett's metaplasia in 2 (histological false positive) and IMC in 1. Thus, overall 14 of 16 (87.5%) patients had complete EMR of the original lesions. In patients who did not undergo esophagectomy, there was no disease recurrence on endoscopic biopsies at a mean follow-up of 8 (IQR, 6-12) months. Three of the 16 patients (18.75%) with post-EMR bleeding were successfully treated with APC/hemoclips. Trimodal imaging endoscopy is a feasible alternative to chromoendoscopy to identify inconspicuous neoplasia and assist EMR of early neoplasia in Barrett's esophagus.

Invasive Cancer in Endoscopic Mucosal Resection Specimens of Non-Nodular Barrett's Esophagus: Implications for Ablative Therapy

Background: Endoscopic mucosal resection (EMR) is well established for resection of Barrett's Esophagus (BE) with high grade dysplasia (HGD) and/or intramucosal cancer (CA). It may be used for curative intent or staging and is considered safe. Complete circumferential resection of long segment BE, however, has been avoided due to elevated stricture risk and increased procedure time. Multiple centers advocate focal EMR of BE nodules followed by bipolar ablation of the remaining involved tissue. Hypothesis: In patients with BE and HGD/CA, malignant tissue may be present in non-nodular mucosa; therefore, complete EMR should be performed to avoid undertreatment of flat cancers.