Endoscopic Mucosal Resection (EMR) Periprocedural Care

Updated: Jun 26, 2017
  • Author: Bruce D Greenwald, MD; Chief Editor: Kurt E Roberts, MD  more...
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Periprocedural Care

Equipment

Tools specific to endoscopic mucosal resection (EMR) are discussed in more detail elsewhere (see Technique). Additional equipment includes the following:

  • Retrieval net or basket for specimen retrieval
  • Injection needle and injection fluid for lifting
  • Hemostatic clips and hemostatic forceps for control of bleeding and repair of small perforations

Specimens should be labeled according to their location (particularly within the esophagus and stomach), spread and pinned at the periphery of the specimen to a backing, and stored in formalin solution.

An EMR device kit has been developed that includes a pathology kit with tissue paper and cassette tray designed to flatten the tissue so as to facilitate accurate margin assessment (Captivator EMR; Boston Scientific, Marlborough, MA). 

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Patient Preparation

As a rule, EMR can be safely performed with procedural sedation. Appropriate consideration should be given to cardiopulmonary comorbidities and anesthesia support.

The procedure is generally performed with the patient in the left lateral decubitus position.

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Monitoring & Follow-up

Surveillance recommendations following EMR are evolving. Series with modest numbers of patients have demonstrated favorable long-term results in appropriately selected patient populations.

Esophagus

Follow-up studies of EMR of early squamous cell carcinoma of the esophagus have demonstrated 5-year survival rates of 95%, with no cancer-related deaths. [13, 43]  In addition, similar 5-year survival comparable to that with esophagectomy has been demonstrated. [44]  Risk factors for recurrence include resection of multiple or large circumferential lesions. [45]

Large series studying EMR for the treatment of high-grade dysplasia (HGD) and intramucosal adenocarcinoma within Barrett esophagus (BE) have demonstrated complete eradication in 60-99% of patients, with a recurrence rate of 11-30% at 3 years. [46, 47, 48]  Risk factors for recurrence and metachronous lesions include larger lesion size, piecemeal resection, long-segment BE (see the video below), incomplete resection, and multifocal dysplasia. [49, 50, 51]

This video, captured via esophagoscopy, shows long circumferential segment of Barrett esophagus. Video courtesy of Dawn Sears, MD, and Dan C Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.

In most instances, metachronous lesions can be treated successfully with repeat EMR. Combination with ablative modalities—for example, photodynamic therapy, liquid nitrogen spray cryotherapy, and radiofrequency ablation (RFA; see the videos below)—may serve to reduce recurrences. Investigations have also reported successful complete eradication of BE in as many as 96.9% of patients with short-segment BE, though concerns have been raised regarding subsquamous BE and stricture rates. [9, 10, 19]

This video shows circumferential Barrett esophagus via esophagoscopy. HALO 360 device is in esophageal lumen, ready to perform radiofrequency ablation. Video courtesy of Dawn Sears, MD, and Dan C Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.
This video, captured via esophagogastroduodenoscopy, shows use of HALO 90 device to perform radiofrequency ablation in patient with Barrett esophagus. Barrett esophagus increases risk of developing esophageal cancer. Video courtesy of Dawn Sears, MD, and Dan C Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.
This video, captured via esophagoscopy, shows Barrett esophagus after having just undergone treatment with radiofrequency ablation using HALO 360. Video courtesy of Dawn Sears, MD, and Dan C Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.

Given the relatively high recurrence rate of BE after ablation, postablation endoscopic surveillance is recommended as outlined in guidelines published by the American College of Gastroenterology (ACG), the American Gastroenterological Association (AGA), and the American Society for Gastrointestinal Endoscopy (ASGE). [52, 53, 54, 18]

Early gastric cancer

The Japanese experience has demonstrated excellent long-term results of EMR for early gastric cancer (EGC). [30, 55]  For example, a study of more than 100 patients reported no local recurrence or distant metastases over 9 years of follow-up. [56]  The primary factors associated with durable remission rates are as follows:

  • Achievement of a resection margin of at least 2 mm
  • Complete en-bloc resection

Additional factors associated with recurrence include multiple synchronous cancers, lesion size greater than 2 cm, and lesion location in the upper body and lesser curvature. [57, 58]

Duodenum

One large study of EMR-ampullectomy reported a success in 84% of 168 patients with a recurrence rate of 8%. [59]  Two additional small series reporting results of EMR for nonampullary lesions demonstrated successful eradication in 100% of patients, with no local recurrence. [60, 61]

Submucosal lesions

Successful resection of submucosal tumors has been reported in relatively small series in 79-95% of patients using ligation-assisted EMR, simple snare, or an insulated-tip knife; however, long-term follow-up data are lacking. [62, 63]  The role of EMR in the evaluation of submucosal lesions rests largely in the acquisition of an adequate specimen for histopathologic analysis in instances of uncertain diagnosis.

Colon

Reports of long-term outcomes following EMR of flat premalignant lesions and early colorectal cancer vary widely, with recurrence rates ranging from 0% to 40%. [64, 65]  Variations in technical expertise and heterogeneity in lesions included for treatment are partially responsible for this wide disparity. Overall, however, most recurrences are amenable to repeat endoscopic treatment during surveillance colonoscopy. As with early gastric cancer, en-bloc resection and lesion size of 2 cm or less are associated with lower local recurrence rates. [25]

Argon plasma coagulation (APC) has been used to ablate resection margins with the aim of reducing local recurrence following piecemeal resection, with mixed results. Two of three well-designed studies reported a reduction in recurrence of up to 50% with the use of APC. [65, 66, 67]

Because of the risk of remnant tissue or local recurrence, close surveillance is generally recommended. Repeat colonoscopy may be performed within as little as 4-6 weeks to ensure that all dysplastic tissue has been resected or ablated. Follow-up colonoscopy with surveillance biopsies is most often performed 3-6 months after EMR, and subsequent surveillance is adjusted according to the status of recurrence.

Endoscopic submucosal dissection

Endoscopic submucosal dissection has emerged as a viable choice for en-bloc resection of superficial gastrointestinal tumors, regardless of size. In Korea and Japan, ESD is routinely performed in the treatment of superficial gastric neoplasia and is becoming the standard treatment for colorectal neoplasia, such as early colorectal cancer or benign colorectal tumors 2 cm or greater in size for which en-bloc resection with conventional EMR is difficult.

A survey of members of the Korean Society of Gastrointestinal Endoscopy/ESD group regarding indications for selecting ESD as a treatment for colorectal tumors 2 cm or greater in diameter showed that for tumors showing a partially nonlifting sign and suspected shallow submucosa-invasive cancer, 42% of endoscopists selected ESD and another 31% selected ESD or surgery. [68] For tumors showing a severe nonlifting sign and suspected shallow submucosa-invasive cancer, 64% selected surgery and another 22% selected ESD or surgery to treat the tumor.

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