Esophageal Endoscopic Mucosal Resection Research Articles

A potential preventive method for scar stenosis after esophageal endoscopic mucosal resection using human amniotic epithelial cells in a porcine model.

ObjectivesThe current methods employed for esophageal endoscopic mucosal resection (EMR) involve the risk of adverse postprocedural complications. Therefore, this study aimed to develop a new method to prevent stenosis following a resection procedure using human amniotic epithelial cells in a porcine model.MethodsWith the consent of a woman who underwent a cesarean section, amniotic epithelial cells were isolated from the amniotic membrane of the delivered placenta. Six swine were used for this study. Under general anesthesia, four EMRs using cap‐fitted microscope ulcers were performed on each porcine esophagus. Of the four ulcers, the two on the oral side were treated by injecting human amniotic epithelial (AE group) cells, and the remaining two on the anal side were left untreated (control group). One week after the procedure, the swine were sacrificed, and the ulcers were evaluated. The epithelialization rate was calculated by dividing the length of the epithelialized portion of each section by the length of the ulcer, which was determined using an optical microscope. Moreover, the mucosal thickening in each section was measured in terms of diameter.ResultsThe epithelialization rate was significantly higher in the AE group than in the control group. Mucosal thickening was not significantly different between the groups.ConclusionsTransplanting amniotic epithelial cells into the ulcer promoted ulcer epithelialization. Amniotic epithelial cell transplantation is a potential method for the management of ulcer scar stenosis following esophageal endoscopic submucosal dissection.

How to Perform a High-Quality Endoscopic Submucosal Dissection

How to Perform a High-Quality Endoscopic Submucosal Dissection

Precut esophageal endoscopic mucosal resection for cervical esophageal cancer to minimize mucosal defect.

A 72-year-old man underwent esophagogastroduodenoscopy (EGD) for heartburn. Two adjacent, iodine-unstained, shallow depressed lesions, 25 mm and 8 mm in size, were found in the cervical esophagus ([Fig. 1]). Biopsies revealed squamous cell carcinoma (SCC). The patient opted for endoscopic resection.

Mo1292 EFFICACY AND OUTCOMES OF ENDOSCOPIC MUCOSAL RESECTION IN T1B ESOPHAGEAL ADENOCARCINOMA: CAN ESOPHAGECTOMY BE AVOIDED IN SELECT PATIENTS?

The incidence of esophageal adenocarcinoma (EAC) has continued to increase over the past several decades. While endoscopic mucosal resection (EMR) is highly effective for intramucosal EAC (T1a lesions), there is limited data on outcomes of patients following EMR with T1b EAC in the era of modern chemoradiation and cryotherapy modalities. While the current standard of care for T1b EAC relies on esophagectomy, with its high risk of morbidity and mortality, it remains uncertain whether select patients with T1b EAC can be definitively treated with EMR along with chemoradiation or additional endoscopic therapies. The aim of this study is to evaluate the outcomes of patients with T1b EAC after initial EMR. A retrospective cross-sectional study was performed using a prospective electronic endoscopy database at a tertiary care academic medical center. All patients who underwent esophageal EMR for T1b EAC between February 2015 and September 2019 were included. Data on patient and disease characteristics were collected. The primary outcome was presence of residual disease (local or metastatic) during follow-up. A total of 13 patients with T1b EAC who underwent EMR were identified. The mean age was 71 years and 85% were male. Seven of these patients (54%) underwent esophagectomy while 6 patients had endoscopic and clinical surveillance. Patients who underwent esophagectomy and endoscopic surveillance had similar characteristics except that patients who underwent esophagectomy had a lower Charlson comorbidity index (5.7 vs. 7.8, P = 0.04). In patients who underwent endoscopic surveillance, 67% were deemed too high-risk for surgery, while 33% refused surgery. Among the 6 patients who underwent endoscopic surveillance after EMR, 3 were additionally treated with cryotherapy, 1 was treated with radiofrequency ablation (RFA) and 1 underwent chemoradiation. One of these 6 patients was found to have residual disease at a mean follow-up of 478 days. Among the 7 patients who underwent esophagectomy after EMR, 3 (43%) had residual tumor on surgical pathology, however none of these 7 patients underwent chemoradiation prior to surgery. Of all 13 T1b EAC patients who underwent EMR, 69.2% (N = 9) had no evidence of subsequent residual disease with a follow-up of 739 days. None of the patients with residual disease underwent prior chemoradiation. These results suggest that select patients with T1b EAC who are at high-risk for esophagectomy may be successfully managed with local therapy of EMR followed by the addition of chemoradiation and alternative endoscopic treatment modalities. Further prospective studies are needed to validate these findings and guide optimal patient selection.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Outcomes of Hemospray therapy in the treatment of intraprocedural upper gastrointestinal bleeding post-endoscopic therapy.

With increasing advances in minimally invasive endoscopic therapies and endoscopic resection techniques for luminal disease, there is an increased risk of post-procedure bleeding. This can contribute to significant burden on patient's quality of life and health resources when reintervention is required. Hemospray (Cook Medical, North Carolina, USA) is a novel haemostatic powder licensed for gastrointestinal bleeding. The aim of this single-arm, prospective, non-randomised multicentre international study is to look at outcomes in patients with upper gastrointestinal bleeds following elective endoscopic therapy treated with Hemospray to achieve haemostasis. Data was prospectively collected on the use of Hemospray from 16 centres (January 2016-November 2019). Hemospray was used during the presence of progressive intraprocedural bleeding post-endoscopic therapy as a monotherapy, dual therapy with standard haemostatic techniques or rescue therapy once standard methods had failed. Haemostasis was defined as the cessation of bleeding within 5 min of the application of Hemospray. Re-bleeding was defined as a sustained drop in haemoglobin (>2 g/l), haematemesis or melaena with haemodynamic instability after the index endoscopy. A total of 73 patients were analysed with bleeding post-endoscopic therapy. The median Blatchford score at baseline was five (interquartile range 0-9). The median Rockall score was six (interquartile range 5-7). Immediate haemostasis following the application of Hemospray was achieved in 73/73 (100%) of patients. Two out of 57 (4%) had a re-bleed post-Hemospray, one was following oesophageal endoscopic mucosal resection and the other post-duodenal endoscopic mucosal resection. Both patients had a repeat endoscopy and therapy within 24 h. Re-bleeding data was missing for 16 patients, and mortality data was missing for 14 patients. There were no adverse events recorded in association with the use of Hemospray. Hemospray is safe and effective in achieving immediate haemostasis following uncontrolled and progressive intraprocedural blood loss post-endoscopic therapy, with a low re-bleed rate.

Experience of using photodynamic therapy in the treatment of esophageal cancer

Photodynamic therapy (PDT) is a worthy alternative to surgical esophageal resection or endoscopic mucosal resection and dissection (EMR, ESD) in patients with superficial esophageal cancer with severe concomitant diseases as well as in patients with a common form of esophageal cancer with severe malignant dysphagia. Patients with superficial (7) and advanced (15) esophageal cancer received PDT as an independent method and as a supplement to complex treatment. Radachlorin was used as a photosensitizer at a dose of 0.6–0.8 mg/kg, administered intravenously 3 hours before irradiation. A PDT session was carried out using a laser with a wavelength of 662 nm. The light dose used was 150–300 J/cm2 . The use of PDT made it possible to achieve the full effect in 7 (100%) patients in the group of superficial (T1a-T1b) esophageal cancer where PDT was either the only method of treatment or in combination with radiation therapy. In the group of patients with stenotic cancer the use of PDT made it possible to achieve full recovery of food intake after recanalization for 20% of patients, and partial – for 66.7%. Thus, complete natural food intake was restored for 86.7% of patients which improved their quality of life. PDT is also a method of choice for cancer of the upper esophagus as esophageal stenting in this situation can cause unwanted subjective sensations.

The Initial Management of T1a Esophageal Adenocarcinoma: A Survey Study

Introduction: Multiple modalities exist for treatment of early esophageal adenocarcinoma cancers (EEAC), including esophagectomy, ESD (endoscopic submucosal dissection) and EMR (endoscopic mucosal resection) combined with radiofrequency ablation (RFA). While these therapies have become an acceptable treatment, no consensus guidelines exist on the management of EEAC post EMR/ESD. The aim of our study is to collect data on how gastroenterologists (GI) and oncologists manage EEACs in order to determine if variations in treatment exist. Methods: A 9-question survey was sent via email to GI and oncologists within the Pennsylvania Societies of Gastroenterology (PSG) and Oncology and Hematology (PSOH). The responses were analyzed for the following: referral practices, type of practice, comfort with managing EEAC; imaging obtained; knowledge and utilization of endoscopic treatment. Results: 38 of 44 respondents treated EEACs and proceeded with the survey. 34 (91.9%) were GI with 3 (8.1%) oncologists participating. 24 (63.2%) practiced in an academic practice, 13 (34.2%) in a large non-academic practice, and 1 (2.6%) in a solo non-academic practice. In treating EEACs, 19 (50%) participants felt very comfortable, 13 (34.2%) felt somewhat comfortable and 6 (15.8%) felt not at all comfortable. 6 (16.2%) participants see more than 10 cases of early EACs yearly, 4 (10.8%) see 5 to 10 cases, and 27 (73%) see 1 to 5 cases. 27 (73%) always obtain a CT scan, 8 (21.6%) sometimes do, and 2 (5.4%) never do. 14 (36.8%) always obtain a PET or PET-CT, 14 (36.8%) sometimes do, and 10 (26.3%) never do. 8 (21.6%) always refer to an oncologist, 23 (62.2%) sometimes refer, and 6 (16.2%) never refer. 7 (18.4%) always refer to a surgeon, 21 (55.3%) sometimes refer, and 10 (26.3%) never refer. 24 (63.2%) believe that EMR with RFA is adequate to treat early EAC, with 12 (31.6%) believing it is sometimes adequate, 1 (2.6%) believing it is never adequate and 1 (2.6%) unfamiliar with the procedures. Conclusion: Our study highlights the variability in levels of comfort in treating EEACs along with differences in obtaining imaging studies, surgical and oncologic referrals and possibly EMR/ESD in treatment. Our results enforce there is no standardized approach to EEACs amongst GI and Oncology physicians. Therefore, we suggest that GI and Oncology societies come together to create consensus guidelines that will help clinicians standardize their evaluation and treatment of these complicated patients.

Efficacy and Safety of Endoscopic Mucosal Resection for Esophageal Lesions in a Private Community Practice Setting

Introduction: Endoscopic mucosal resection (EMR) can be performed for a variety of esophageal lesions. EMR offers an effective, safe and minimally invasive alternative to the conventional surgical approach and in conjunction with radiofrequency ablation (RFA), has virtually eliminated esophagectomy for patients with dysplastic Barrett's and intra-mucosal cancer (IMC). However, in a community hospital setting endoscopists mostly had avoided it due to fear of complications, especially perforation. The aim of this study is to review our results of EMR for esophageal lesions with respect to efficacy and safety to better define its utility in a private community practice setting. Methods: This is a retrospective analysis of patients who underwent esophageal EMR between Jan 1st 2014 and July 31st 2016 at our center. Patient's demographics, procedural details, complications and histopathology were analyzed and reported. Results: A total of 115 patients underwent 140 EMR procedures (Tables 1 and 2). The mean age was 66.5 ± 11.9 years and 77% were males. The majority of the EMR were performed in the setting of nodular Barrett's with or without dysplasia (48.6%) and adenocarcinoma (29.3%). EMR was applied to a variety of other mucosal lesions in the esophagus as well. Multiband mucosectomy (MBM) was utilized in the majority of procedures (94.3%). In patients with Barrett's esophagus, EMR in combination with ablation was able to eradicate dysplasia or IMC in 28/32 patients (87.5%). Intra-procedural bleeding occurred in 42 cases (30%), but immediate hemostasis was achieved in all and in majority with the tip of the snare with soft coagulation current. Two patients (1.74%) developed delayed bleeding and one required endoscopy to control bleeding successfully. Four patients (3.7%) with more than 75% circumferential resections, developed strictures, two of them required dilation. There was no case of perforation. Mean operative time was 34.5 ± 14.6 minutes.Table: Table. Summary of Patients' DemographicTable: Table. Histopathological Characteristics of Lesions and Procedure DetailsConclusion: Our results are comparable to previous studies investigating the eradication of Barrett's esophagus with dysplasia and rate of stricture development. Our data shows that EMR is safe and effective diagnostic and therapeutic tool for advanced Barrett's, early esophageal cancer and a variety of other esophageal lesions.Figure: The schematic shows the basic steps of Endoscopic Mucosal Resection.Figure: The images shows different steps involved in Endoscopic Mucosal Resection of the esophageal nodules.

Non-radical, stepwise complete endoscopic resection of Barrett's epithelium in short segment Barrett's esophagus has a low stricture rate.

Background and aims: Radical endoscopic excision of Barrett’s epithelium performing 4 – 6 endoscopic resections during the same endoscopic session results in complete Barrett’s eradication but has a high stricture rate (40 – 80 %). Therefore radiofrequency ablation is preferred after endoscopic mucosal resection (EMR) of visible nodules. We investigated the clinical outcome of non-radical, stepwise endoscopic mucosal resection with a maximum of two endoscopic resections per endoscopic session. Methods: We analysed our prospectively maintained database of patients undergoing esophageal EMR for early neoplasia in Barrett’s esophagus from 2009 to 2014. EMR was performed using a maximum of two band ligation mucosectomies per endoscopic session; thereafter, follow-up was 3-monthly and EMR was repeated as required for Barrett’s eradication. Results: In total, 118 patients underwent staging EMR for early Barrett’s neoplasia. Subsequently, 27 patients underwent surgery/chemotherapy due to deep submucosal or more advanced tumor stages or were managed conservatively. The remaining 91 patients with high grade dysplasia (48), intramucosal (38) or submucosal cancer (5) in the resected nodule underwent further endoscopic therapy with a mean follow-up of 24 months. Remission of dysplasia/neoplasia was achieved in 95.6 % after 12 months treatment. Stepwise endoscopic Barrett’s resection resulted in complete Barrett’s eradication in 36/91 patients (39.6 %) in a mean of four sessions; 40/91 patients (44.0 %) had a short circumferential Barrett’s segment (< 3 cm). In this group, repeated EMR achieved complete Barrett’s excision in 85.0 %. One patient developed a stricture (1.1 %), one a delayed bleeding, and there were no perforations. Conclusion: In patients with a short Barrett’s segment, non-radical endoscopic Barrett’s resection at the time of scheduled endoscopy follow-up allows complete Barrett’s eradication with very low stricture rate.

PTH-007 Non-Radical, Stepwise Complete Endoscopic Resection of Barrett’s Epithelium in Short Segment Barrett’s Oesophagus is Effective with Low Stricture Rate

<h3>Introduction</h3> Radical endoscopic ablation of Barrett’s epithelium performing 4–6 endoscopic resections during the same endoscopic session has been shown to result in complete Barrett’s ablation but has a high stricture rate (40–80%). Therefore radiofrequency ablation is preferred for the ablation of Barrett’s epithelium after endoscopic mucosal resection (EMR) of visible nodules. We investigated whether non-radical, stepwise endoscopic mucosal resection with maximal 2 endoscopic resections per endoscopic session can result in complete remission of intestinal metaplasia and dysplasia in short segment Barrett’s oesophagus. <h3>Methods</h3> We analysed our database of patients undergoing oesophageal EMR for early neoplasia in Barrett’s oesophagus from 2009 to 2014. Patients showing poorly differentiated cancer or advanced cancer (&gt;T1sm₂) after staging EMR were excluded. In patients suitable for further endoscopic therapy, EMR was performed using maximal two band ligation mucosectomies per endoscopic session; thereafter followup was 3 monthly and EMR was repeated as required for Barrett’s ablation. If no dysplasia was detected after a year, the follow up interval was increased to 6 months. <h3>Results</h3> 118 patients underwent staging EMR for early Barrett’s neoplasia. Subsequently, 27 patients underwent surgery/chemotherapy due to deep submucosal or more advanced tumour stages or were managed conservatively depending on patient’s fitness, comorbidities and choice. 91 patients with HGD (48), intramucosal (38) or submucosal cancer (5) in the resected nodule underwent further endoscopic therapy with a mean follow-up of 24 months (8–36 months IQR). Remission of dysplasia/neoplasia was achieved in 94.5% after 12 months treatment. Stepwise endoscopic Barrett’s resection resulted in complete Barrett’s ablation in 36 patients (39.6%) in a mean of 4 sessions. 40 patients (43.9%) had a short circumferential Barrett’s segment (C &lt; 3 cm). In this group, repeated EMR achieved complete Barrett’s ablation in 85.0%. One patient developed a stricture (1.1%), one a delayed bleeding, there were no perforations. <h3>Conclusion</h3> In patients with short Barrett’s segment, non-radical endoscopic Barrett’s resection at the time of scheduled endoscopy follow up allows complete Barrett’s ablation with very low stricture rate. <h3>Disclosure of Interest</h3> None Declared

Endoscopic ultrasound making resonance in cancer research

Endoscopic ultrasound (EUS) is a novel technology that is being increasingly used for the diagnosis and management of cancers involving various organ systems. The technology was introduced three decades ago and its use has expanded exponentially in the past two decades. EUS-guided fine needle aspiration (FNA) is the best modality for tumor detection and tissue diagnosis even if the mass is weakly identified by other imaging modalities (1). EUS-FNA is capable of taking samples from masses that are not imaged by computed tomography or magnetic resonance imaging and lesions too deeply encased by adjacent vascular structures to allow percutaneous biopsy (2). EUS-guided FNA as well as EUS guided Trucut biopsy (TCB) has proven to be beneficial for benign and malignant diseases as well as staging of malignant tumors of the GI tract and adjacent structures (3). The application of EUS-guided therapy is especially appealing for malignancies because it provides accurate and effective palliative treatment. This is possible primarily due to two EUS characteristics: (I) its ability to deliver direct treatment to lesions unreachable by other means; and (II) the minimal invasiveness of EUS, which provides superior results with a low complication rate (4). EUS is being used to locally stage esophageal tumors (T staging), and it can be used for the assessment of esophageal submucosal tumors as well. Based on the EUS characteristics, we can positively identify the lesions that arise from exterior layers. This approach is particularly useful for evaluating invasion of local disease (especially esophageal cancer), tumor depth, nodal involvement, and detection of distant metastases (5). CT and magnetic resonance imaging lack the ability to differentiate the layers of the esophageal mucosa. Thus, these modalities cannot accurately discern the T stage of esophageal cancer (6). Therefore, EUS is a prerequisite before performing esophageal endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). Esophageal leiomyomas, esophageal cancers, cystic lesions, lipomas, vascular lesions, and esophageal extraluminal compressions are some of the lesions that are commonly identified using EUS. EUS can be used to obtain cytology specimens from mediastinal nodal enlargement for the diagnosis and staging of bronchogenic carcinoma (7). EUS has a definitive role for evaluation of early gastric cancers and gastric submucosal lesions. Early gastric cancers can be staged using EUS and the feasibility of EMR or ESD can be determined. Gastrointestinal stromal tumors (GISTs) and other submucosal lesions can be diagnosed as well using EUS and their potential for ESD can be determined using EUS.

Low Bleeding Rates Associated With Esophageal Endoscopic Mucosal Resection for the Treatment of Dysplastic Barrettʼs Esophagus: ACG Governors Award for Excellence in Clinical Research

Low Bleeding Rates Associated With Esophageal Endoscopic Mucosal Resection for the Treatment of Dysplastic Barrettʼs Esophagus: ACG Governors Award for Excellence in Clinical Research

Endoscopic mucosal resection of early oesophageal neoplasia in patients requiring anticoagulation: is it safe?

Endoscopic mucosal resection (EMR) has become the standard treatment for early oesophageal neoplasia. The mucosal defect caused by EMR usually takes several weeks to heal. Despite guidelines on high-risk endoscopic procedures in patients on anticoagulation, evidence is lacking whether EMR is safe in such patients. We investigated the immediate and delayed bleeding risk in patients undergoing diagnostic or therapeutic oesophageal EMR comparing patients requiring warfarin anticoagulation with a control group. Warfarin was stopped 5days before the planned EMR and restarted on the evening following the procedure. Patients with high-risk conditions, such as recent pulmonary thromboemboli, received bridging with low molecular weight heparin. All EMRs were performed when the INR was <1.5. Bleeding events on the day of the EMR and within 3months post-procedure were documented. One hundred and seventeen consecutive patients with early oesophageal neoplasia were included. Sixty-eight EMRs were performed in 15 patients requiring anticoagulation. One patient on warfarin was readmitted 10days after EMR with haematemesis and melaena. Out of 400 EMRs in 102 controls, 26 immediate bleeding events occurred requiring endoscopic intervention. One delayed bleeding event (melaena) occurred in the control group. The number of bleeding events did not differ between groups [p=0.99; odds ratio 1.01 (0.30-3.44)], neither for acute (p=0.76) nor delayed bleeding (p=0.24). EMR of early oesophageal neoplasia can be safely performed in patients requiring anticoagulation when warfarin is discontinued 5days before the endoscopic intervention and reinstituted on the evening of the procedure day.

217 Comparison of the Histopathological Effects of Two Electrosurgical Currents in an In-Vivo Porcine Model of Esophageal Endoscopic Mucosal Resection

Stenosis is the main limitation of endoscopic resection (ER) in the esophagus. The optimal electrosurgical current (ESC) for ER in the esophagus and other gastrointestinal sites is presently unknown. There may be a relationship between the type of ESC used and the likelihood of post ER esophageal stricture (PERES) formation. Unlike low power coagulating current (LPCC), microprocessor controlled alternating short pulse cutting with coagulating current (MCC) avoids high peak voltages that are thought to result in deep thermal injury.

Tu1734 Endoscopic Resection of Esophageal Neoplasia: Comparison of Endoscopic Submucosal Dissection (ESD) With Endoscopic Mucosal Resection (EMR) in Our Institution

Endoscopic submucosal dissection (ESD) is widely accepted as a more reliable therapeutic procedure for superficial gastrointestinal tract neoplasms compared with endoscopic mucosal resection (EMR). However, ESD for esophageal neoplasms is still associated with a high complication rate compared with EMR. For elderly patients in particular, only a few reports have evaluated the feasibility and safety of esophageal ESD. In this study, we compared consecutive elderly patients undergoing esophageal ESD with those undergoing esophageal EMR to evaluate the efficiency and complications of ESD.

PTU-024 Non-radical, Stepwise Endoscopic Ablation Of Barrett’s Epithelium In Short Segment Barrett’s Oesophagus Has Low Stricture Rate

IntroductionRadical endoscopic ablation of Barrett’s epithelium performing 4–6 endoscopic resections during the same endoscopic session has been shown to result in complete Barrett’s ablation but has a high stricture rate...

Tu1328 Endoscopic Submucosal Dissection for Barrett's Esophagus: Efficacy and Safety Results in a Large Tertiary Center Series of Patients

Tu1328 Endoscopic Submucosal Dissection for Barrett's Esophagus: Efficacy and Safety Results in a Large Tertiary Center Series of Patients

Predictors of esophageal stricture formation post endoscopic mucosal resection.

Background/AimsStricture formation is a common complication after endoscopic mucosal resection. Predictors of stricture formation have not been well studied.MethodsWe conducted a retrospective, observational, descriptive study by using a prospective endoscopic mucosal resection database in a tertiary referral center. For each patient, we extracted the age, sex, lesion size, use of ablative therapy, and detection of esophageal strictures. The primary outcome was the presence of esophageal stricture at follow-up. Multivariate logistic regression was used to analyze the association between the primary outcome and predictors.ResultsOf 136 patients, 27% (n=37) had esophageal strictures. Thirty-two percent (n=44) needed endoscopic dilation to relieve dysphagia (median, 2; range, 1 to 8). Multivariate logistic regression analysis showed that the size of the lesion excised is associated with increased odds of having a stricture (odds ratio, 1.6; 95% confidence interval, 1.1 to 2.3; p=0.01), when controlling for age, sex, and ablative modalities. Similarly, the number of lesions removed in the index procedure was associated with increased odds of developing a stricture (odds ratio, 2.3; 95% confidence interval, 1.3 to 4.2; p=0.007).ConclusionsStricture formation after esophageal endoscopic mucosal resection is common. Risk factors for stricture formation include large mucosal resections and the resection of multiple lesions on the initial procedure.

Commercially available biological mesh does not prevent stricture after esophageal mucosectomy

Endoscopic mucosal resection (EMR) offers a minimally invasive therapy for advanced esophageal dysplasia and early cancers but stricture formation limits its applicability. We aimed at assessing the efficacy of placement of a commercially available biological mesh for preventing stricture formation following esophageal EMR. 25 swine were submitted to circumferential esophageal EMR with 10-cm extent and divided in five groups: one group with EMR only (control); one receiving an uncovered stent (stent-only group); and three groups receiving a stent covered with one of three extracellular matrices, namely small intestine submucosa (SIS group), acellular dermal matrix (ADM group), or urinary bladder matrix (UBM group). Stricture formation was evaluated with weekly esophagograms. The stent-only group had significantly less stricture formation and survival was extended compared with controls (4.8 vs. 2.4 weeks). Compared with stenting only, the addition of a biological mesh did not reduce stricture formation: percent reductions in esophageal diameter for the groups were SIS 86 %, ADM 94 %, and UBM 94 %, compared with 82 % in the stent-only group. Placement of commercially available biological meshes did not alter remodeling sufficiently to prevent stricture formation after esophageal EMR.

Impact of endoscopic mucosal resection in patients referred for endoscopic management of Barrett's esophagus

Abstract Background Barrett's esophagus (BE) may be managed by radiofrequency ablation, endoscopic mucosal resection (EMR), and surgical resection for advanced lesions. The goal of this study was to evaluate the impact of EMR in patients referred for management of BE. Methods All patients referred to a tertiary center for management of BE between January 1, 2009 and August 7, 2012 were reviewed and stratified according to dysplasia, Barrett's-related neoplasm, and nodularity. Endpoints included histopathologic characterization of esophageal tissue biopsies and EMR specimens, discrepancy between diagnoses, and subsequent change in management following EMR. Results In total, 2648 endoscopies were reviewed. Thirty-five patients having a total of 38 EMRs were included. Mucosal tissue biopsy and EMR specimens were discordant in 24 of 38 specimens (63%). Of these, 20 biopsy results were upstaged (53%) and four downstaged (10.5%) following EMR. The most common change was upstaging to invasive adenocarcinoma. EMR diagnosed 13 cases of invasive carcinoma, 12 of which were upstaged (92%). Based on EMR results, management was changed in 13 cases (34%), primarily to surgery. Conclusion Mucosal biopsies and EMR results were discrepant in 63% of cases, with 53% resulting in an upstaged diagnosis. Approximately one-third of these patients had a change in management. In patients referred for BE, EMR was found to be fundamental to accurate grading and should be a component in the evaluation and management of Barrett-related lesions.