Transcript EMR training program day 1 ER

Endoscopic resection in Barrett’s:
ER-cap, MBM or ESD?
Indications for ER in Barrett’s
• In general:
– Unifocal, limited size (< 2cm);
– Mucosal lesions;
– Well / moderately differentiated neoplasia:
• How do I know it’s mucosal?
– Endoscopic appearance;
– Endoscopic ultrasound
– ER as a diagnostic procedure
Histological evaluation ER specimen:
The most important step of the diagnostic work-up.
Treatment concept and
considerations
ER
RFA
LGIN
HGIN
IMC
Surgery
superficial
sm invasion
deep
sm invasion
Treatment concept and
considerations
All visible lesions or suspicious areas require
endoscopic resection!
Submucosal lifting
Lifting sign (Adrenalin 1:20.000)
Kato type 1: complete/soft
Kato type 2: complete/hard
Kato type 3: incomplete
Kato type 4: “non-lifting sign”
(Kato et al, Endoscopy 2001, 33: 568-573)
Submucosal lifting
Injection Technique
• Start with injecting at the distal margin;
• In tubular esophagus: lesion at 6 o’clock position;
• In distal esophagus: retroflex;
• Insert the needle tangential to esophageal wall;
• Start fluid injection just before insertion;
• Start injecting at the edges;
• Avoid injection through lesion.
Submucosal lifting
Submucosal lifting
Type 3: Incomplete lifting
All sm1-sm3
Submucosal lifting
Type 4: “no lifting” sign
All sm3
ER-cap, MBM or ESD?
ER-cap vs.MBM technique
Randomised trial
ER-cap
(n=22)
MBM (n=23)
pvalue
4 (2-8)
5 (3-9)
ns
50 (29-65)
29 (16-52)
0.04
2
12
0
9
ns
ns
Max. diameter of ER-specimens (mm)
21 (19-25)
18 (15-20)
0.00
Max. thickness of ER-specimens (mm)
2.0 (1.80-2.20)
1.9 (1.6-2.15)
0.393
Max. thickness of submucosa (mm)
1.0 (0.50-1.13)
0.8 (0.551.00)
0.363
Costs disposables/procedure, euro’s
322 (275-474)
240 (240-484)
0.01
Number of resections/procedure
Procedure time (min)
No. complications: Severe (perforation)
(bleeding)
Mild
Pouw et al. Gastrointest. Endosc. 2011
ER-cap vs.MBM technique
Randomised trial
• Piecemeal ER with MBM is faster and cheaper than with
the ER-cap technique;
• MBM may be associated with fewer complications;
• MBM results in significantly smaller sized resections;
• MBM may, therefore, be more suited for resection of flat
lesions with a low risk of submucosal invasion;
• The ER-cap technique may be preferred for ER of
elevated and nodular lesions.
Pouw et al. Gastrointest. Endosc. 2011
ER-cap technique
ER-caps
• Hard caps, straight or oblique,
Ø: 12.8-14.8 mm.
• Hard, wide caps, straight or oblique,
Ø: 16.1 mm.
• Large flexible oblique caps,
Ø: 18 mm.
ER-caps
General rules
• Oblique caps for most lesions.
• Straight caps only for lesions that can be
approached en-face (e.g. greater curvature stomach).
General rule
• Size of the cap = size of specimen.
Large caliber cap for en-bloc resections.
• Size of
the capcap
= for
depth
of resection.
Standard
piecemeal
resections.
Matzusaki et al Gastrointest. Endosc.2003
ER-caps
• Different diameters to fit differently sized endoscopes.
• Choose right cap for endoscope.
• Fix with water resistant tape.
• Introduction hard cap can be difficult.
ER-cap procedure
Snares
Crescent shaped, single use ER snare
ER-cap procedure
Snare placement
• Snare is placed in the distal ridge inside the cap.
• Position cap at an area with normal mucosa.
• Seal (not fill) the cap with gentle suction.
• Open snare slowly, keep tip at 6-9” position.
• Ideally the snare should open clockwise.
ER-cap procedure
Snares
Location lesion prior to resection
Position the lesion at 6 o’clock
Location lesion prior to resection
Position the lesion at 6 o’clock
For lesions at the 12 o’clock
position:
Avoid resection with the endoscope
in an angulated position
Rotate the endoscope to position
the lesion at the 6 o’clock position
Suck and catch
• Test suction prior to placement of snare may be useful.
• Amount of aspiration of mucosa in cap determines size
resected specimen.
• En-bloc resections: go for complete “red-out”, be more
conservative for piecemeal procedures.
• Tighten snare quickly until resistance is encountered.
Resection
• Resect outside the cap.
• Hold the snare by yourself!
• Re-open 1-2 mm, inflate esophagus and shake specimen.
• Pre-coagulation for 1-2 seconds.
• Use either coagulation or Endocut for further resection.
• Erbe ICC 200:
pre-coagulation: 1-2 sec 45 Watt.
transsection: Endocut 120 Watt, effect 3.
Suck, shake and cut
Multi-Band Mucosectomy (DuetteR)
Multi-Band Mucosectomy (DuetteR)
• Modified variceal band ligator:
Widened threading channel of the cranking device from 2 to 3.2 mm,
allowing introduction of 7F accessories alongside the thread.
• 7F accessories:
Not only a snare, but also an APC probe, spraying catheter, clipping
device or hot biopsy forceps.
Multi-Band Mucosectomy (DuetteR)
• Transparent cap with 6 rubber bands, to create a pseudopolyp;
• Hexagonal snare for resection using electrocautery,
reusable due to shape stability.
Multi-Band Mucosectomy (DuetteR)
• A pseudopolyp is created by suctioning mucosa into the cap,
and releasing a rubber band;
• The snare should be placed below the rubber band;
• The snare should be closed tighter than with the cap-
technique;
• Use pure coagulation (ICC 200, 45 W), usually the polyp is
resected after 1 to 2 seconds.
Mounting of the EMR device
• Do not use the irrigation adapter of the set to puncture
and widen the opening of the cranking device!
• Fix the Duette barrel properly.
• During fixing of the barrel, take care of the outer
covering of the scope which may be damaged
• Align trigger cords preferrably at 6-12 o´clock position
(Olympus scope).
Ensure good visualization
place the cap correctly
Technical difficulties
decreased visibility due to bands and wires
Release some bands if you expect to perform en-bloc resection.
Model
Endoscope
Snare
Working channel
DT-6
9.5-13mm
7-Fr
3.7
DT-6-5F
9.5-13mm
5-Fr
2.8
DT-6-XL
11-14mm
7-Fr
3.7
Piecemeal ER in BE using MBM
Before ER
• Therapeutic endoscope preferred due to better
suction ability;
• Clean the area for ER of any secretion;
• Marking of the lesion by APC:
– 2-5 mm outside the lesion’s margins
– Tip of snare: Erbe ICC 200, 45 Watt
– APC: Erbe ICC 200 + APC 300, 40 Watt.
• Suck out all fluids from the stomach !!!
Piecemeal ER
What to target first?
• Try to remove the most involved area in a single piece,
usually in the first resection;
• The lateral edges of each resection are the most superficial
so avoid cutting through the area where you expect the
deepest infiltration.
Piecemeal ER
Subsequent resections
• Target the second resection area;
• Variables:
•Relative position of the cap to the resection wound;
•Size of the cap;
•Amount of aspiration of mucosa into the cap.
• ER-cap: repeat lifting before every subsequent resection;
• Always perform a test suction (and prior to placement of
snare when using ER-cap).
Safety and efficacy of multiband mucosectomy
in 1060 resections in Barrett's esophagus
Prospective registration
Complications
n=170 (resections: 1060)
Perforation
0% (0/243)
Delayed bleeding
2.1% (5/243)
Herrero A. et al. Endoscopy 2011;43:177
Soehendra N. et al. GIE 2008;
En-bloc vs. Piecemeal ER
piecemeal resection
• Enables widespread ER;
• Technically more challenging than en-bloc resections;
• Bigger risk of complications;
• Recurrences appear more often after piecemeal procedures.
Practical aspects
Tips & Tricks I
• To prevent perforation do not suck too much at the EG
junction and in a hiatal hernia.
• Avoid "red out phenomenon“ (suction of the tissue all the
way to the lens).
Practical aspects
Tips & Tricks II
• Torque the scope to appropriately locate the lesion
according to the distal opening of the working channel to
facilitate snaring.
• Avoid touching the pseudopolyp:
– do not move the barrel beyond the pseudopolyp
– extend and open the snare beyond the pseudopolyp
– pull the opened snare back and place it around the
pseudopolyp
Overlap vs. irradical resection
• Avoid too much overlap to prevent perforation;
• Less than 25% overlap is acceptable:
resection is usually less deep at the overlapping lateral
margins than at the centre of the resection;
• Avoid residual Barrett’s tissue between adjacent resections;
• Be liberal with submucosal injection in the resection area.
Additional ablation residual tissue
APC 60-80 Watt
Useful in case of (very) small residual isles of target tissue
between subsequent resections or between markings and the
outer wound margin.
Retrieval specimens
•
Always retrieve specimens for histopathological evaluation.
•
This can be done at the end of the procedure.
•
Retrieval: aspirate in cap (single specimen) or foreign body
basket (multiple specimens).
•
Pin specimen on paraffin/cork before fixation.
ESD
ESD in early Barrett's cancer ?
ER Cap
ESD
p
none (1-11 pieces)
96%
<0.0001
1488 (185-3194)
2453 (600-5400)
<0.01
61(20-130)
150 (64-334)
<0.001
Devices costs (Euro)
264 (60-515)
486 (247-1019)
<0.001
R0 (free lat & deep
margins)
24%
64%
<0.05
CR neoplasia
100%
100%
ns
CR intest metaplasia
84
84
ns
Perforation
1
2
ns
En-bloc resection
Surface resected mm2
time (min)
Deprez P. et al. DDW 2010
ESD in early Barrett's cancer ?
• n=18 (3f/15 m)
• HGIN/IMC up to 3cm
• median diameter: (15-30 mm)
• "en bloc" resection: 15 (83.9%)
• Pneumomediastinum: 1
• Horizontal free margin: 5 (28%)
Neuhaus H. et al. DDW 2010
ESD in early Barrett's cancer ?
• Considerable for "visible lesions" larger
than 2 cm.
Wound inspection and treatment of
complications
Treatment algorithm post-ER bleeding
Bleeding after
endoscopic resection
Minor oozing
Observe for 1-2 min.
OR
careful coagulation with
tip of snare
Spurting bleeding
-
Grasp vessel/bleeding area
with coagulation forceps
(max. 2 times)
If unsuccessful or
inadequate visualization:
•Reposition patient?;
•Inject adrenaline 1:10,000 (2-5 cc)
and repeat coagulation
OR
•Place hemoclip.
Treatment of post-ER bleeding with
the tip of the snare
(ICC200 45 Watt)
Treatment using hot biopsy forceps
(ICC 200 soft coag, 80 W)
What to do in case of a
perforation?
Esophageal
Gastric
Transmural resection
specimen
Immediate management of
esophageal perforations
• Place suction tube at the site of the
perforation.
• Limit inflation (emphysema).
• Esophagography watery contrast medium.
Perforations
Surgical or conservative treatment?
•
Have you completely eradicated the neoplasia?
Will surgery be required anyway?
•
What’s the size and the location of the defect?
Surgery is easier for gastric than esophageal perforations.
Small defects may be treated endoscopically.
•
Does the patient have relevant co-morbidity?
Beware: optimal timing for surgery is <24 hours.
Perforations
Non-surgical management
• Close defect with clips (stomach).
• Place covered stent.
• Antibiotics and PPIs.
• Nil per mouth.
Treatment of perforations
placement of a covered stent
Perforation as seen
through the cap
Conservative treatment
by stent placement
Healed esophagus after
8 weeks
Treatment of perforations
perforation closed with clips and an endoloop
"tulip bundle technique'
Perforation as seen
through the cap
Perforation closed with
clips and an endoloop
Healed esophagus after
4 months
Questions?