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suboptimal.

PreoperativePlanning

■ Allpatientsshouldundergoathoroughhistoryandphysicalexaminationandbe classifiedbasedontheAmericanSocietyofAnesthesiologists(ASA)score.

■ InterventionsinpatientswithASAscoregreaterthanorequalto4arenot deemedbeneficial,astheriskofharmoutweighsthepotentialbenefits.

■ Obtainingroutinelaboratorydatasuchaswhitebloodcellandplateletcount, bleedingstudies(partialthromboplastintime[PTT]/internationalnormalized ratio[INR]),andcreatinineandelectrolytesismainlyindicatedin multimorbidpatientsorthosetakingmedicationsthatspecificallyaffectany organorsystem(e.g.,anticoagulant,diuretics).

■ Managementofanticoagulantspreoperativelyshouldbebasedontheguidelines establishedbytheAmericanSocietyforGastrointestinalEndoscopy.

■ Inpatientswithhigh-riskcardiovascularconditionsonwarfarin,itisimportant tobridgethisperiodwiththeuseoflow-molecularorfractionatedheparins.

■ ProphylacticantibioticsarenotrecommendedbeforeEMR.

■ Thestandardofcareistheadministrationofconscioussedation.

4,5,12,15

■ Exceptionsincludepatientswhoingestnarcoticsorbenzodiazepines, multimorbidpatients,orheavyalcoholdrinkers.Forthesegroupsofpatients, weprefermonitoredanesthesiacare(MAC),useofnurse-assistedpropofol sedation(NAPS),orgeneralanesthesia(GA).

■ WewanttoemphasizethatacarefullyperformedEMRinexperthandsshould takelessthan15minutes.

■

WhenperforminganEMR,thebulkoftimeisusuallyinrecognizingand characterizingthelesion.Theresectionperseisafocusedprocedurethat shouldbetargeted,efficientandefficacious.

Positioning

■ Thepatientisplacedintheleftlateraldecubituspositionandpreparedasfora routineupperendoscopy.

TECHNIQUES

ENDOSCOPICMUCOSALRESECTIONTECHNIQUES

■ SeveralEMRtechniqueshavebeendescribedforremovaloffocalanddiffuse lesionsinBE.

4,5,12,15

■

Table1liststheessentialequipmentneededforEMR.

SNARETECHNIQUE

■ Thisisthemost“simple”techniquetoremovealesion.

4,5,15

■

Itentailsusinganovalorhexagonalelectrocauterysnare.

■ However,simplerefersmainlytothecommonlyusedinstrumentstoperforman EMR,asitrequireshigh-levelskillsandexperiencetobeabletograspthe targetlesionandresectitentirelybyjustusingasnare.

■ Itisimportanttoalwaysremovealltheairbeforesnaringthelesion.Thisallows forensnaringmoretissue.

■ Theassistantholdingthesnareshouldcarefullycloseitwhiletheendoscopist aspiratestheairandadvancesthesnarecathetertowardthelesion.

■ TheelectrocauteryusedforperformingEMRshouldbepredominantlycutor blended.

■ Coagulationcurrentstendtoproducedeepinjuryandareassociatedwithhigh riskofperforation.

SUBMUCOSALINJECTIONANDSNARE

■ Amodificationofthesnaretechniqueistheuseofasubmucosalcushionbelow thetissuetoberemoved.

4,5,12

■ This“safety”cushionmaytheoreticallydecreasetherisksofperforation.

■ Byiatrogenicallyswellingupthemucosawiththeinjectionofsubstances,itwill beharderforthepathologisttodeterminethedepthoftumorinvasion(if present).

■ Wealsocautionagainsttheuseofepinephrineinthesolutionusedtocreatethe submucosalcushionasthevenousirrigationfromthedistalesophagusreturns totherightheartwithoutfirst-passmetabolismthroughtheliverviathe azygousvein,thusincreasingthechanceofsystemiceffectsandsideeffects, includingcardiacischemia.

USEOFATRANSPARENTCAP(“SUCK-AND-CUT”OR INOUETECHNIQUE)

■ Atransparentcapisattachedtothetipofthescope.

■ Thecapisplacedperpendicularlyagainstthemucosa,preferentiallyinthe greatercurvatureofthestomach.Asnareisadvanced,opened,andplaced aroundtheinnerringofthecap(FIG6).

■ Oncethesnareispartiallyopened,completelyinsidetheinnerpartofthecap, thescopeispulledbackintotheesophagusanddirectedtowardthelesionof interest.

■ Thelesionisthenaspiratedinsideofthecapandthesnareisclosedsnuggly aroundthebaseofthelesion(FIG7).

■

Oncethelesionhasbeencaughtwiththesnare,electrosurgicalcurrentsare appliedandthelesionisresected(FIG8).

USEOFCAPWITHLIGATUREDEVICE(“SUCK-LIGATEAND-CUT”TECHNIQUE)

■ Withthismethod,boththemucosaandsubmucosaareaspiratedor“sucked”into atransparentcaploadedwithelasticligaturebandsorrings(FIG9).

■ Thisdeviceisessentiallythesameastheonetoperformesophagealvariceal ligation.

■ Whereassomeexpertsusea“multiband”ligator(MBL),usingasingle-band ligationdeviceisalsopossible.

■ Afterplacingthebands,thescopeisretrieved,thecapisremoved,andthescope

isreinsertedtoperformtheEMR.

■ Byaspirating(“sucking”)thetissueintothecapandreleasingtheringonits base,apseudopolypiscreated(FIG10).

■ ThemainadvantageoftheDuette®-MBL(CookMedical,WinstonSalem,NC) isthata5-Frpolypectomysnarecanbepassedthroughboththeligatorhandle andchannelofthescope,thuspermittingligationandsubsequentresection usingthesnarewithoutremovaloftheendoscope(FIG11).

■ The“pseudopolyp”isthensnaredoff.

■ AnadvantageofusinganMBLmethodisthecreationofoneormultiple pseudopolyps.

■ TheMBLmethodsisagreatoptionfor(1)removinglesionslocatedinvarious

sites,(2)piecemealEMRofalargerlesion,and/or(3)toperformhemi-or fullcircumferentialresectionofthedistalesophagealmucosa.

■ ResectedspecimensarecollectedusingthesnareRothNet(USEndoscopy, Mentor,OH)oraspiratedintotheinsideofthecapofthescopeandretrieved outoftheesophagusorstomach.

■ Thepiece(s)shouldbefixedontoapieceofcorkorStyrofoambeforebeing immersedin4%formalinsolutionandsentforhistopathologicassessment.

PEARLSANDPITFALLS

Patientevaluation ■Carefulhistory,endoscopicfindings,andpathologic

reviewofrecordsshouldbedonepriortoselection ofpatientsforEMR.

Indication ■EMRisonlyindicatedforlesionslessthan20mm.

Endoscopy ■Endoscopicidentificationoflandmarksandlength

onsegmentshouldbebasedonthePrague classification.

■Knowledgeofchromoendoscopyandadvanced

endoscopicmethodsisessentialforasuccessful EMR.

■Thechromoendoscopydevicesshouldbeready

beforetheproceduregetsstarted.

■Carefuldescriptionanddocumentationoftheexact

locationofthelesionismandatory.

■Useadiagramtodocumentfindings.

■Endoscopicphotodocumentationismandatory.

EMR method/technique

■EMRshouldbeonlyperformedbyendoscopists

withadvancedendoscopictraining.

■Becomewell-versedinoneEMRtechnique.

■Removetheairbeforeensnaringthelesion.

■Bereadyforpotentialcomplications(bleeding,

perforation)andknowhowtotreatthem.

■Eachresectedspecimenshouldbepinneddowninto

corkorStyrofoamandplacedintodistinctlylabeled formalincontainers.

■Alwayshaveanadditionallargehexagonaland

smallovalsnarereadilyavailable.

Follow-up ■AllpatientsundergoingEMRshouldbeputonlong-

termprotonpumpinhibitors.

■AllEMRcasesshouldbepresentedatthepathology

conference.

■Follow-upendoscopyismandatorytoensure

completeresectionandevaluateforsynchronousor metachronouslesionsorrecurrence.

■AllpatientsundergoingEMRshouldbekeptina

registrytoensurequalitycare.

POSTOPERATIVECARE

■ Aliquiddietisadministeredfor24hoursaftertreatmentandthenadvancedto regulardiet.

■ AllpatientsundergoingEMRshouldbeonlong-termprotonpumpinhibitors.

■ ThedosageisdoubledafterEMRandkeptatthislevelfor4weeks.

■ Patientsareusuallydischargedhomeonthesamedayoftheprocedure.

■ Follow-upendoscopyisbasedonthetypeandhistologyoflesionresected.

■ Long-termfollow-upisbasedontherecommendationsoftheAmericanCollege ofGastroenterologyandAmericanSocietyforGastrointestinalEndoscopy.

OUTCOMES

■ EMRisefficaciousmethodtotreatBEwithhigh-gradedysplasiaandearly canceraslongasthelesionsarelessthan20mm.

4,5,12,15

■ Inexperthands,completeremissionsofmorethan95%canbeachieved.

4,5,12,15

■ Afavorableoutcomeisdependentonthefollowing“low-risk”criteria:invasion notbeyondsm1,absenceofinfiltrationintolymphvesselsand/orveins, histologicgradeG1/2,andmacroscopictypeI/II.

■ Recurrenceormetachronousneoplasiaareseeninupto20%to30%ofpatients.

■ Repeatendoscopictreatmentcanbeperformedinalmostallpatientspresenting withmetachronousorrecurrentdisease.

■ Ablativetherapyusingradiofrequencyablationoftheresidualorrecurrent Barrettsegmentispossible,feasible,andeffective.

COMPLICATIONS

■ EMRhaslowcomplicationratesinexperthands.

■ Earlycomplicationsincludeperforation(<0.5%)andbleeding(5%to14%).

■ Moderateorseverepost-EMRbleedingcanbeeasilycontrolledbydiluted epinephrineinjection(1:10,000)and/ormetalclipapplication.

■ Esophagealstenosisismorecommoninpatientsundergoingresectionofmore than50%ofthedistalesophagealcircumference

REFERENCES

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