Mucosectomy Technique Research Articles

Evaluation of Antireflux Mucosectomy for Severe Gastroesophageal Reflux Disease: Medium-Term Results of a Pilot Study.

Background Antireflux mucosectomy, a new endoscopic treatment for gastroesophageal reflux disease, consists of endoscopic mucosal resection at the esophagogastric junction. This study aim was to evaluate the medium-term efficacy of the antireflux mucosectomy technique for patients with severe gastroesophageal reflux disease symptoms (proton pump inhibitor treatment-dependent or proton pump inhibitor treatment-resistant gastroesophageal reflux disease). Methods Between January 2017 and June 2018, 13 patients with severe gastroesophageal reflux disease without hiatal hernia, with positive pH reflux, were included in this monocentric prospective pilot study. The primary outcome was clinical success, defined by improvement evaluated by the Gastroesophageal Reflux Disease Health Related Quality of Life Questionnaire at 24 months. Secondary outcomes were technical success, decreased use of proton pump inhibitors, patient satisfaction, and adverse events. Results Thirteen patients [females = 8 (62%)], mean age 59 (range, 54-68), were included. The antireflux mucosectomy procedure had technical success in all patients. At 24 months, for 11 patients, gastroesophageal reflux disease symptoms were significantly improved, and mean gastroesophageal reflux disease score decreased from 33 (range, 26-42) to 3 (range, 0-7) (p = 0.001). Ninety-one percent (n = 10) of patients had a lower proton pump inhibitor intake at 24 months. One patient had 3 endoscopic balloon dilatations for EGJ stenosis, two patients had melena ten days after procedure, and seven patients had thoracic or abdominal pain. Patient's satisfaction at 24 months was 81%. Conclusions In patients with severe gastroesophageal reflux disease, despite occurrence of several short-term adverse events, antireflux mucosectomy seemed effective in improving gastroesophageal reflux disease symptoms at 24 months. This trial is registered with ClinicalTrials: NCT03357809.

Endoscopic management of Barrett's dysplasia and early neoplasia: efficacy, safety and long-term outcomes in a UK tertiary centre.

Endoscopic mucosal resection (EMR) and radiofrequency ablation (RFA) are effective treatments for dysplastic Barrett's esophagus (BE). This study evaluates efficacy, durability and safety in a single high-volume UK tertiary centre with 15-years' experience. Prospective data were collected from Nottingham University Hospitals 2004-2019 for endotherapy of dysplastic BE or intramucosal adenocarcinoma. Procedural outcome measures include complete resection, complications and surgery rates. Efficacy outcomes include complete remission of dysplasia (CR-D) and intestinal metaplasia (CR-IM), recurrence, treatment failure rates, durability of RFA, median follow up and tumor-associated mortality. A total of 319 lesions were resected; 671 RFAs were performed on 239 patients. Median age was 67 (±9.5) years, male:female ratio was 5:1 and median BE length was C3 [interquartile range (IQR): 6] M6 (IQR: 5). The most common lesion was Paris IIa (64%) with a median size of 10 mm (3-70). Final histology was adenocarcinoma in 50%. Complete resection rates were 96%. The multiband mucosectomy technique (91%) was most commonly used. The median number of RFA sessions was 3 (IQR: 2). The rates of CR-D and CR-IM were 90.4%% and 89.8% achieved after a median of 20.1 (IQR: 14) months. The most common complications: EMR was bleeding 2.2% and RFA was stricture (5.4%) requiring a median of 2 (range 1-7) dilatations. Median follow up post CR-IM/CR-D was 38 months (14-60). Metachronous lesions developed in 4.7% after CR-D and tumor-related mortality was 0.8%. Dysplasia and intestinal metaplasia-free survival at 5 years was 95 and 90%, respectively. BE endotherapy is minimally invasive, effective, safe and deliverable in a day-case setting.

Prophylactic Snare Tip Soft Coagulation and Its Impact on Adenoma Recurrence After Colonic Endoscopic Mucosal Resection.

Up to 20% of patients can have recurrence of adenomatous tissue at first surveillance study after colon endoscopic mucosal resection of large polyps. To determine whether an educational intervention discussing thermal ablation of lateral margins of the mucosectomy site of post-endoscopic mucosal resection defect with snare tip soft coagulation (STSC) would decrease adenoma recurrence. We performed a single-center quality improvement project from November 1, 2016, to November 30, 2017. Gastroenterologists underwent an educational intervention demonstrating the treatment of peripheral margins of mucosectomy site with STSC after standard mucosectomy technique. These cases (intervention group) were compared with consecutive procedures performed prior to commencement of the quality improvement study (pre-intervention group). Patients with large colorectal lesions (≥ 20mm) were included. Of the 120 patients here included, overall demographics of the groups were similar and the most common histology was sessile serrated adenoma (study group 45% vs 32% control group). Adenoma recurrence on intervention group and pre-intervention group was 12% versus 30%; p = 0.01. On univariate analysis, biopsy prior to mucosectomy, intraprocedural bleeding, and application of STSC on mucosectomy defect were the strongest predictors of adenoma recurrence. Adenoma recurrence in the intervention group was significantly lower than in the pre-intervention group in both univariate (odds ratio, 0.3 [95% CI, 0.11-0.80]) and multivariate analyses (odds ratio, 0.2 [95% CI, 0.12-0.92]). The implementation of STSC of post-endoscopic mucosal resection peripheral defects is clinically feasible and significantly decreased adenoma recurrence.

A Rare Case of Hyperplastic Proximal Esophageal Polyps With Foveolar Dysplasia

A 62-year-old male with long-standing esophageal reflux underwent endoscopy at an outside institution that reported multiple polypoid lesions in upper esophagus and a small focal area of nodular mucosa at the gastroesophageal junction(GEJ). Biopsies of the proximal esophageal polyps demonstrated hyperplastic mucosa with ulceration, reactive epithelial changes, and focal intestinal metaplasia. Biopsies from the nodular GEJ mucosa were described as Barrett’s esophagus with low grade dysplasia. An upper endoscopy performed at our medical center found multiple semi-pedunculated esophageal polyps between 18-24 cm from the incisors (Figure A).Endosonographically the polypoid lesions were confined to the mucosa with normal underlying wall layers (Figure B). Patient underwent endoscopic mucosal resection (EMR) using a multi-band mucosectomy technique. Hematoxylin and eosin staining of the EMR specimens showed gastric and intestinal metaplasia, featuring cubital to columnar cells with pale clear to light eosinophilic cytoplasm and round to oval nuclei (Figure C). MUC5AC (a marker of gastric foveolar mucin) was positive in the specimen (Figure D); whereas intestinal markers MUC2, CDX-2 and Villin, were negative. The impression of the gastrointestinal pathologists was hyperplastic polyp with foveolar dysplasia. At a follow-up endoscopy 3 months later, smooth mucosal scarring was noted with no residual polypoid tissue or gastric heterotopia.

Hidden in Plain Sight: The Value of Ex Vivo Volumetric Laser Endomicroscopy in Confirming Neoplastic Changes Within a Barrettʼs Nodule

Volumetric Laser Endomicroscopy (VLE) utilizes next generation optical coherence tomography to produce high-resolution cross-sectional imaging via a swept source laser. Usage to date has focused on the evaluation of Barrett's esophagus (BE), specifically identification of features consistent with dysplasia and neoplasia. A 66 year old male was referred for evaluation and treatment of BE found by his local gastroenterologist to have developed multi-focal low grade dysplasia between surveillance endoscopies in 2013 and 2016. The patient was scheduled for upper endoscopy with mapping BE biopsies. Key findings included a 3 cm hiatal hernia and a BE segment classified as C2-M3 by Prague criteria. Within this segment was a subcm nodule located 1 cm proximal to the top of the gastric folds (Figure 1). VLE of the distal esophagus revealed diffuse loss of normal wall layer architecture, consistent with BE, along with a focal area of abnormal epithelial glands suspicious for dysplasia located on the opposite wall from the nodule. The region near the nodule contained a topographical surface, but no clear suspicious glands were appreciated. The nodule then was resected using a cap-band-ligator with snare mucosectomy technique. An ex vivo VLE scan was performed on the nodule. Images demonstrated multiple areas of markedly abnormal-appearing epithelial glands with some containing what appeared to be necrotic material. These changes were suspicious for high grade dysplasia (Figure 2).Figure 1Figure 2Figure 3Pathology from the resected specimen showed extensive BE with high grade dysplasia. Comparison of the tissue sample and the ex vivo VLE images confirmed a very similar morphologic appearance in both specimens. This case highlights how the limitations of in vivo VLE when nodularity is present to distort normal esophageal anatomy can be overcome through use of the technology following endoscopic resection. The topographical nature of the nodule prevented optimal tissue contact with the VLE probe, resulting in suboptimal in vivo visualization of the highly irregular glandular structures contained within the nodule. Routine use of this technology following resection, especially when images are compared with pathology specimens, can provide confirmation that the appropriate region of concern has been removed from the esophagus.

Endoscopic submucosal resection of gastric subepithelial lesions smaller than 20 mm: a comparison of saline solution–assisted snare and cap band mucosectomy techniques

Application of endoscopic submucosal resection (ESMR) in the management of gastric subepithelial lesions (GSLs) less than 20mm is gradually increasing because it allows diagnosis and treatment at the same operative session. In this study, we compare and evaluate the benefits of ESMR with an endoscopic cap band mucosectomy technique or saline solution-assisted snare technique in GSLs smaller than 20mm. This was a retrospective analysis of a prospectively maintained database used at 2 academic tertiary care centers. A total of 63 patients (34 females, mean age 52 years) with endoscopically resected GSLs were included in this study. The mean tumor size determined by EUS was 12.3mm (range, 5-20mm). Sixty-seven percent of the GSLs were localized in the antrum in all groups. The endoscopic cap band mucosectomy technique was used to resect 32 (50.8%) GSLs, whereas 31 (49.2%) were resected with the saline solution-assisted snare technique. The en bloc resection rates were 97% for the saline solution-assisted snare technique and 100% for the endoscopic cap band mucosectomy. Intraoperative bleeding occurred in 1 of 31 patients (3.2%) when ESMR was performed with the saline solution-assisted snare technique. Postoperative bleeding was seen in 1 of 32 patients (3.1%) who underwent the endoscopic cap band mucosectomy technique. In GSLs smaller than 20mm, ESMR with saline solution-assisted snare or endoscopic cap band mucosectomy techniques is safe, the adverse event rate is low, accurate diagnosis is achieved, and treatment with en bloc resection is provided in a single session. Given similar success and adverse event rates, saline solution-assisted ESMR may be the preferred technique because of its lower cost advantages.

Single-session endoscopic resection and focal radiofrequency ablation for short-segment Barrett’s esophagus with early neoplasia

The management of early neoplasia in Barrett's esophagus (BE) requires endoscopic resection of visible lesions, followed by radiofrequency ablation (RFA) of the remaining BE. We evaluated the safety and efficacy of combining endoscopic resection and focal RFA in a single endoscopic session in patients with early BE neoplasia. This was a retrospective analysis of patients with early BE neoplasia and a visible lesion undergoing combined endoscopic resection and focal RFA in a single session. Consecutive ablation procedures were performed every 8 to 12 weeks until complete endoscopic and histologic eradication of dysplasia and intestinal metaplasia were reached. Forty patients were enrolled, with a median C1M2 BE segment, a visible lesion with a median diameter of 15mm, and invasive carcinoma in 68% of cases. Endoscopic resection was performed by using the multiband mucosectomy technique in 80% of cases, and the Barrx(90) catheter (Barrx Medical, Sunnyvale, Calif) was used for focal ablation. When an intention-to-treat analysis was used, both complete remission of all neoplasia and intestinal metaplasia were 95% after a median follow-up of 19 months. Stenoses occurred in 33% of cases and were successfully managed with a median number of 2 dilations. In 43% of patients, 1 single-session treatment resulted in complete histologic remission of intestinal metaplasia. Combining endoscopic resection and focal RFA in a single session appears to be effective. Less-aggressive RFA regimens could limit the adverse event rates.

Combined Laparoscopic Intragastric Stapled Resection with Endoscopic Mucosal Resection Technique for the Gastric Gastrointestinal Stromal Tumor Localized in Cardia

Introduction: Neoplastic tumors localized close to the gastroesophageal (GE) junction are often a challenge both for the surgeon and the patient.1 The procedure is usually connected with extensive resection of stomach and part of the esophagus. It is fully justified for cancer treatment with the necessity of regional lymphadenectomy. In the case of primary gastrointestinal stromal tumors (GISTs), standard surgical treatment is based on local excision.2–4 In the video, we present our modification of intragastric resection of GIST combining laparoscopic stapled resection with endoscopic mucosal resection, which leads to an effective en block resection of the GIST in a difficult localization. Materials and Methods: An 81-year-old female was qualified for the surgical treatment of the 3 cm cardia GIST. An asymptomatic tumor was diagnosed during the routine gastroscopy. A preoperative CT scan confirmed that there were no metastases to the liver and that the tumor was limited to the stomach wall. In the video, we present a novel variant of minimally invasive approach for this kind of tumor—a combination of laparoscopic and advanced endoscopic methods. During intraoperative gastroscopy, the presence of GIST localized close to the GE junction was confirmed. The base of the tumor was stapled. The remaining part of the mucosa between the tumor and stomach wall was removed using the mucosectomy technique. The specimen was retrieved through the mouth. Results: There were no intra- and postoperative complications. The pathological report confirmed R0 resection of CD117-positive GIST with MI 4/50 high power field.5 In the follow-up CT scan and gastroscopy after 3 months, we did not find a recurrent tumor. Conclusion: We strongly believe that laparoscopic intragastric stapled resection has the potency to become a standard procedure for the treatment of GISTs localized near the GE junction. In the enclosed video, we showed that in the case of a wide base of the tumor, our modification—a combination of stapling and mucosectomy—is a valuable alternative. No competing financial interests exist. Runtime of video: 5 mins 51 secs

Modification to stapled mucosectomy technique with PPH. Experience of a surgical group

Abstract Background Haemorrhoidal disease is a common disorder. Surgical treatment is indicated in cases of advanced disease. However, postoperative pain, operative time, and technical difficulties have prompted the search for new procedures and improve the existing ones. A modification is proposed to the technique of PPH (Procedure for Prolapse and Haemorrhoids) stapled haemorrhoidectomy that facilitates and standardises the procedure without altering its benefits. Objective To describe the postoperative results and short-term evolution of patients with internal haemorrhoidal disease, who underwent stapled mucosectomy with PPH with a modified technique. Materials and methods This is a retrospective review of 35 patients who underwent stapled haemorrhoidectomy with a modified technique by the same surgical team. Results Twenty-five patients were men (71%) and 10 women (29%). Sixteen patients had grade III internal haemorrhoid disease (46%) and 19 grade IV (54%). The mean operative time was 31 min. Six patients had acute urinary retention. There were no cases of severe pain, bleeding, haematoma, stenosis, incontinence, thrombosis, or re-operation. The median hospital stay was 1 day. Conclusions The proposed modification of PPH haemorrhoidectomy is performed with greater technical ease without increased morbidity, preserving the advantages of the original technique.

Preliminary results of antiscarring therapy in the prevention of postendoscopic esophageal mucosectomy strictures

Esophageal endoscopic submucosal dissection (ESD) is an effective minimally invasive therapy for early esophageal cancer and high-grade Barrett dysplasia. However, esophageal stricture formation after circumferential or large ESD has limited its wide adoption. Mitomycin C(MMC), halofuginone (Hal), and transforming growth factor β3 (TGF-β3) exhibits antiscarring effects that may prevent post-ESD stricture formation. Using endoscopic mucosectomy (EEM) technique, an 8- to 10-cm-long circumferential esophageal mucosal segment was excised in a porcine model. The site was either untreated (control, n=6) or received 40 evenly distributed injections of antiscarring agent immediately and at weeks 1 and 2. High and low doses were used: MMC 5mg (n=2), 0.5mg (n=2); Hal 5mg (n=2), 1.5mg (n=2), 0.5mg (n=2); TGF-β3 2μg (n=2), 0.5μg (n=2). The degree of stricture formation was determined by the percentage reduction of the esophageal lumen on weekly fluoroscopic examination. Animals were euthanized when strictures exceeded 80% or the animals were unable to maintain weight. The control group had a luminal diameter reduction of 78.2±10.9% by 2weeks and were euthanized by week 3. Compared at 2weeks, the Hal group showed a decrease in mean stricture formation (68.4% low dose, 57.7% high dose), while both TGF-β3 dosage groups showed no significant change (65.3% low dose, 76.2% high dose). MMC was most effective in stricture prevention (53.6% low dose, 35% high dose). Of concern, the esophageal wall treated with high-dose MMC appeared to be necrotic and eventually led to perforation. In contrast, low dose MMC, TGF-β3 and Hal treated areas appeared re-epithelialized and healthy. Preliminary data on MMC and Hal demonstrated promise in reducing esophageal stricture formationafter EEM. More animal data are needed to perform adequate statistical analysis in order to determine overall efficacy of antiscarring therapy.

Ileal pouch anal anastomosis with modified double-stapled mucosectomy-the experience in China

To investigate the feasibility and long-term functional outcome of ileal pouch-anal anastomosis with modified double-stapled mucosectomy. From January 2002 to March 2011, fourty-five patients underwent ileal pouch anal anastomosis with modified double-stapled mucosectomy technique and the clinical data obtained for these patients were reviewed. Patients with ulcerative colitis (n = 29) and familial adenomatous polyposis (n = 16) underwent ileal pouch-anal anastomosis with modified double-stapled mucosectomy. Twenty-eight patients underwent one-stage restorative proctocolectomy, ileal pouch anal anastomosis, protective ileostomy and the ileostomy was closed 4-12 mo postoperatively. Two-stage procedures were performed in seventeen urgent patients, proctectomy and ileal pouch anal anastomosis were completed after previous colectomy with ileostomy. Morbidity within the first 30 d of surgery occurred in 10 (22.2%) patients, all of them could be treated conservatively. During the median follow-up of 65 mo, mild to moderate anastomotic narrowing was occurred in 4 patients, one patient developed persistent anastomotic stricture and need surgical intervention. Thirty-five percent of patients developed at least 1 episode of pouchitis. There was no incontinence in our patients, the median functional Oresland score was 6, 3 and 2 after 1 year, 2.5 years and 5 years respectively. Nearly half patients (44.4%) reported "moderate functioning", 37.7% reported "good functioning", whereas in 17.7% of patients "poor functioning" was observed after 1 year. Five years later, 79.2% of patients with good function, 16.7% with moderate function, only 4.2% of patients with poor function. The results of ileal pouch anal anastomosis with modified double-stapled mucosectomy technique are promising, with a low complication rate and good long-term functional results.

Predictive factors for histological discrepancy between endoscopic biopsies and endoscopic mucosal resection specimens in Barrett's dysplasia/early neoplasia

Introduction Accurate diagnosis of high grade dysplasia (HGD) or early cancer (EC) is of paramount importance in the management of Barrett9s oesophagus. Endoscopic biopsies are the standard method for the diagnosis of HGD/EC but discrepancies have been reported between biopsies and endoscopic mucosal resection (EMR) specimens. The aim of this study was to investigate the predictive factors for histological discrepancy between endoscopic biopsies and EMR specimens. Methods Prospectively collected data on all EMRs performed for Barrett9s HGD or EC in our institution over a 4-year period were analyzed. Histology of pre-resection biopsies and EMR specimens was retrieved from pathology records. Cases with diagnostic discrepancies between biopsies and EMRs were compared with those without discrepancies. Multivariate linear regression analysis was used with size of lesion, endoscopic morphology, length of Barrett9s, number of targeted biopsies, age and sex of patients as predictive factors. Results 59 lesions from 57 patients (43 men, mean age: 67 ± 11.2) who underwent EMR were studied. Mean length of Barrett9s was 5.2 ± 3.4 cm (range 1–13) and the mean size of lesions was 15.5 ± 4.9 mm (range 7–30 mm). Elevated (Paris 0-Is or 0-IIa) lesions were observed in 31 (52.5%) and flat/depressed lesions (0-IIb or 0-IIc) in 28 (47.5%) of cases. The mean number of pre-resection targeted biopsies was 3.1 ± 1.01 (range 1–5). The ‘band and snare’ mucosectomy technique was used in 46 (78%) and the cap-assisted technique in 13 (22%) EMR cases. Post-EMR histological diagnosis was HGD in 22 (37.3%) and carcinoma in 37 (62.7%) cases. The histological discrepancy rate was 44% (26/59). EMR upgraded the histological diagnosis in 22 (37.3%) cases and downgraded it in 4 (6.8%) resections. On multivariate linear regression analysis, Conclusion Obtaining 3 or more targeted biopsies per lesion improves the histological correlation between endoscopic biopsies and EMR specimens in patients with Barrett9s early neoplasia.

Usefulness of endoscopic ultrasonography (EUS) for selecting carcinoid tumors as candidates to endoscopic resection

Carcinoid tumors (CTs) represent the most common type of neuroendocrine tumors (NETs). Digestive CTs in the gastroduodenal and colorectal tracts may be assessed using endoscopy and echoendoscopy or endoscopic ultrasonography (EUS) with the goal of attempting local resection with curative intent without having recourse to surgery. Endpoints in this study included:--Assessing the usefulness of EUS for selecting CTs as candidates to endoscopic excision. --Assessing the effectiveness of local resection (complete carcinoid resection) and the safety (complications) of the technique involved. OUr series included 18 patients (12 males and 6 females) with 23 tumors. Sixteen patients (10 males and 6 females) were selected, with age ranging from 40 to 81 years (mean: 57 years), biopsied, endoscopically treated digestive carcinoid tumors, and a previous negative extension study. Twenty-one 2-to-20-mm (mean size 8 mm) tumors were resected in 23 procedures. After endoscopy plus biopsy and echoendoscopy (EUS), excision was carried out with conventional polypectomy snare mucosectomy and submucosal injection with saline and/or adrenaline in most cases (15), and mucosectomy technique following lesion ligation with elastic bands for six cases. Two cases underwent transanal endoscopic surgery (TEM), one of them following non-curative polypectomy. A total of 23 local procedures were performed with the key goal of assessing efficacy (complete resection: CR) and safety (complications). There were no severe complications except for the last gastric mucosectomy for a 6-mm carcinoid, where a miniperforation occurred that was solved by using 3 clips (1/23: 4.3%).EUS sensitivity was 94%. Complete resection was 90.5% (19/21). The endoscopic mucosal resection of selected carcinoid tumors is a safe, effective technique. EUS is the technique of choice to select patients eligible for endoscopic resection (carcinoids smaller than 20 mm in superficial layers, with an unscathed muscularis propria and negative extension study).

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.

A Randomized Prospective Trial Comparing the Cap-Technique and Multi-Band Mucosectomy Technique for Piecemeal Endoscopic Resection in Barrett's Esophagus

A Randomized Prospective Trial Comparing the Cap-Technique and Multi-Band Mucosectomy Technique for Piecemeal Endoscopic Resection in Barrett's Esophagus

Single-band mucosectomy for granular cell tumor of the esophagus: safe and easy technique

Mucosectomy involves resection of a digestive wall fragment that frequently removes a part or even all of the submucosal mass. The single-band mucosectomy technique was used to remove a granular cell tumor (GCT) of the esophagus. Only 3% of GCTs, which are relatively uncommon neoplasms, arise in the esophagus. Ultrasonography has allowed for more frequent recognition and better definition of this disease. Until recently, surgical resection of the esophagus has been the only treatment alternative to endoscopic surveillance. Endoscopic techniques such as mucosal resection (EMR), laser, and argon plasma have been proposed as safe and effective alternatives to surgery. However, to date, only a few reports of these endoscopic techniques have been published. This study aimed to evaluate the safety and feasibility of single-band mucosectomy for removing a GCT of the esophagus. Six patients (1 man and 5 women; mean age, 45 years) with a GCT were studied between January 2000 and May 2004. They underwent EMR after endoscopic ultrasonography. The EMR was performed with a diathermic loop after injection of saline solution into the esophageal wall. Only one session was necessary for removal of the tumor from all 6 patients, and no complication was observed. During a mean clinical endoscopic follow-up period of 36 months, no recurrences, scars, or stenoses were observed. These findings show EMR to be a safe and effective technique that allows complete removal of GCTs. Furthermore, this technique provides tissue for a definitive pathologic diagnosis, which laser and argon plasma do not provide. We recommend EMR as the treatment of choice for GCTs after an accurate ultrasonographic evaluation.

Endoscopic mucosal resection.

Endoscopic mucosal resection (EMR), or mucosectomy technique, developed by Japanese endoscopists consists of resecting flat and polypoid neoplasms of the mucosa by longitudinal section through the submucosa. This technique is relatively simple and carries a low morbidity. It represents an important advance for endoscopists in both technical and cancer areas. Compared with the endoscopic methods of tumor destruction (laser, plasma coagulation), EMR presents the advantage of obtaining a complete specimen for histologic analysis.

Transanal mucosectomy: A modification of the Soave procedure for Hirschsprung's disease

In the Soave procedure for Hirschsprung's disease, the mucosectomy of the aganglionic segment of colon is performed transabdominally. The authors describe an innovative modification of the standard Soave procedure, in which a transanal mucosectomy is performed as the abdominal incision is made. The transanal mucosectomy technique was compared with the conventional approach. From 1974 to 1993, 51 patients underwent a Soave procedure for Hirschsprung's disease. Twenty-six (51%) had the standard Soave procedure (STD) (1974–1984), and 25 (49%) had the modified procedure (MOD) (1984–1994). In the latter, the entire mucosal dissection was performed through a transanal approach. Surgical data were accumulated by database analysis. Each case was entered into a database at the time of operation, and follow-up data were obtained through mail-in questionnaires or personal communication. The two groups were comparable with respect to number, gender distribution, and average age at the time of operation. There were two superficial wound infections in the STD group and two superficial wound infections and one death (secondary to cardiac arrest in a patient with trisomy 21 and a severe congenital cardiac anomaly) in the MOD group. The average postoperative stay for the STD group was 10.8 days; that for the MOD group was 6.8 days ( t test: P < .0001). The operating time was shorter for the MOD procedure. Follow-up data were available for 25 (96.2%) patients in the STD group and 25 (100%) in the MOD group. The two groups were comparable in all respects except for the average length of follow-up, which was longer for the STD group. No patients had urinary incontinence or sexual dysfunction (when applicable). Overall, patients/parents in both groups rated the outcome as “good”. This modification of the Soave technique for Hirschsprung's disease is both safe and effective. Compared with the standard procedure, it is associated with shorter operating time (because the transanal mucosectomy is performed as the abdomen is opened) and a shorter stay postoperatively. The results have been excellent.

Technique of transanal endoscopic microsurgery.

Sessile adenomas are predominantly localized in the rectum and lower sigma. Surgical removal is indicated but often implies an invasive surgical procedure. Using conventional transanal surgical techniques, only the lower rectum can be reached and there are high rates of recurrence. The new technique combines an endoscopic view of the rectum under gas insufflation via a stereoscopic telescope with conventional surgical preparation and suturing. Adenomas can be excised using the mucosectomy technique or full-thickness-excision, whereas carcinomas should be excised using full-thickness excision with a sufficient border of healthy mucosa. In carcinomas of the sacral cavity, we remove the retrorectal fat up to the fascia of Waldeyer, including the regional lymph nodes. Transanal endoscopic microsurgery is the most economical and tissue-saving surgical technique for the removal of rectal adenomas and early rectal carcinomas.