1. Endoscopic Mucosal Resection Dr. Howard Mertz Clinical Assistant Professor Vanderbilt University Saint Thomas Hospital Nashville TN

2. Acknowledgements Wilson Cook support for this presentation Olympus support for EMR training

3. Background: Endoscopic removal of superficial lesions in the GI tract feasible This allows full pathologic evaluation superior to surface biopsies Can be curative Can prevent surgery

4. Background: Endoscopic Mucosal Resection (EMR) now done more widely and safely Targets –Large sessile colon polyps –Esophageal dysplasia or early cancers –Gastric cancers or benign tumor nodules –Duodenal polyps

5. 5 Layers of the GI tract by EUS EUS Histology Mucosa MM SubMuc MP Serosa

6. Submucosal (SM) Invasion Increases risk of lymph node metastases –Esoph Ca: sm1 8-30%, sm2 23%, sm3 44% –Gastric Ca: SM 2-25% –Colon Ca: SM 10-18% If definite and more than superficially into SM layer by EUS, avoid EMR If SM on path: surgery or Chemo/RT

7. Patient Selection and EUS: EUS to evaluate depth except in polyps Avoid EMR if submucosal cancer No lymphadenopathy Benign lesions deep in the submucosa Avoid if previous snaring that will tether lesion down with scar tissue

8. T1, N0 Rectal Cancer Mass confined To mucosal layer Can be resected Transanal or by EMR

9. Rectal Cancer T2,N0

10. Nodule in Barretts Esophagus

11. T1-2N1

12. Mucosal Lesion Evaluation 53 yo man with heartburn and nodule in Barretts epithelium. EUS: mucosal/submucosal lesion mp> sm>

13. Submucosal Injection: Create fluid cushion in submucosa Protects muscularis propria from perforation Volumes between 5 and 20 cc Use Sclerotherapy needle Injection fluids can be normal or hypertonic saline, D50, Hyaluronic acid Methylene blue and epinephrine helpful

14. Submucosal Injection: Normal Saline 18.5 cc Epinephrine (1:10,000) 1 cc Methylene blue 0.5 cc If gastric, use D50 or methyl cellulose, due to faster diffusion Haber, Lennox Hill NY

15. Submucosal Injection: Start on distal side of lesion Inject several location Look for lift up of lesion over cushion Failure to lift indicates deeper penetration, contraindication to EMR Methylene blue shows the cushion

16. Marking Tips Mark lesion with burns from needle knife or polypectomy snare tip or APC Can use indigo carmine or other dyes Inject enough so cushion extends well beyond markings Snare halfway up cushion

17. Techniques Inject and snare Inject, band and snare Inject, suction cap, snare

18. Devices Injection needle Stiff snares: Hex snare best, braided helpful Combined needle-snare (US Endo I snare) Cap EMR on EGD scopes –Olympus EMR kit—largest, angled or straight –Cook Duett—variceal type bander, smaller Roth net for retrieval of specimens

19. Lift and Snare

20. Lift and Snare EMR

21. Inject, Cap EMR, Snare

22. Inject, Band, Snare

23. Mucosal Lesion Evaluation 53 yo man with heartburn and nodule in Barretts epithelium. EUS: mucosal/submucosal lesion mp> sm>

24. Endoscopic Mucosal Resection Submucosal Elevation Banding Snare Injection Resection Pathology: inflammatory polyp in Barretts

25. Inject, Cap EMR, Snare

26. How to Ensure Successful EMR Case selection: avoid non-lifting, difficult to access, near circumfrential disease Can be more aggressive in rectum Attempt en bloc resection when possible Carefully resect, biopsy, burn residual Close follow up < 6 months to recheck site Discuss option of surgery

27. Risk of Perforation Highest –Duodenum – Colon, Esophagus – Stomach – Rectum Lowest Reported Rates 0.1-5%

28. How to minimize Perforation Avoid hot biopsy forceps if possible Ensure good mucosal lift before snaring Reinject saline if EMR taking more time and cushion diffusing out Lift with snare prior to cauterizing

29. Bleeding Risk Size < 1cm0% Size 1-2 cm4% Size 2-3 cm24% Size >3 cm32% By Site: Esophagus 11%, Stomach 28%, Duodenum 33%, Colon 17%

30. How to Minimize Bleeding Slow steady closure of snare during cautery Blended current or all coag Argon laser to cauterize and bleeders No anti-coagulants or NSAIDS for 2 weeks May avoid epi to allow any bleeding to be overt initially

31. Summary EMR is available and feasible Requires expertise, EUS helpful Complications include perforation (approx 2%) and bleeding (approx 6%) Curative if mucosal disease only Can prevent surgery