Sections

Endoscopic Mucosal Resection (EMR) and Endoscopic Submucosal Dissection (ESD)

Sections Endoscopic Mucosal Resection (EMR) and Endoscopic Submucosal Dissection (ESD)
Overview
Periprocedural Care
Technique
Medication
Laboratory Medicine
Media Gallery
Tables
References

Periprocedural Care

Equipment

Tools specific to endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) 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.

Patient Preparation

As a rule, EMR and ESD 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.

Technique

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Peters FP, Kara MA, Rosmolen WD, ten Kate FJ, Krishnadath KK, van Lanschot JJ, et al. Stepwise radical endoscopic resection is effective for complete removal of Barrett's esophagus with early neoplasia: a prospective study. Am J Gastroenterol. 2006 Jul. 101 (7):1449-57. [QxMD MEDLINE Link].
Qumseya B, Panossian AM, Rizk C, Cangemi D, Wolfsen C, Raimondo M, et al. Predictors of esophageal stricture formation post endoscopic mucosal resection. Clin Endosc. 2014 Mar. 47 (2):155-61. [QxMD MEDLINE Link]. [Full Text].
Pech O, Behrens A, May A, Nachbar L, Gossner L, Rabenstein T, et al. Long-term results and risk factor analysis for recurrence after curative endoscopic therapy in 349 patients with high-grade intraepithelial neoplasia and mucosal adenocarcinoma in Barrett's oesophagus. Gut. 2008 Sep. 57 (9):1200-6. [QxMD MEDLINE Link].
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Media Gallery

Principles of mucosal resection.
Schematic of lesion penetration as determined by high-frequency endoscopic ultrasonography (EUS).
Endoscopic view of superficial gastric neoplasm.
Probe-based high-frequency ultrasound image of superficial gastric neoplasm.
Transparent endoscopic mucosal resection (EMR) cap.
Endoscopic mucosal resection (EMR). Resection specimen reveals negative deep and lateral margins.
Endoscopic mucosal resection (EMR). Aspiration of tissue during ligation-assisted EMR.
Superficial gastric neoplasm (arrow) demonstrated with chromoendoscopy prior to cap-assisted endoscopic mucosal resection (EMR).
Endoscopic mucosal resection (EMR). Combined cap-and-snare device.
Paris classification of superficial gastrointestinal neoplasms.
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 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 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.
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.
Endoscopic submucosal dissection (ESD). Mucosal lesion defined with high-definition white-light imaging.
Endoscopic submucosal dissection (ESD). Thermal mucosal marking of lesion.
Endoscopic submucosal dissection (ESD). Circumferential mucosal incision.
Endoscopic submucosal dissection (ESD). Submucosal dissection.
Endoscopic submucosal dissection (ESD). Completion of submucosal dissection
Endoscopic submucosal dissection (ESD): stomach.

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Table 1. Lymph Node Metastasis Risk for T1 Tumor at Different Sites in Gastrointestinal Tract^[33]

Table 1. Lymph Node Metastasis Risk for T1 Tumor at Different Sites in Gastrointestinal Tract ^[33]

Depth	Esophageal Squamous Cell Carcinoma	Esophageal Adenocarcinoma	Gastric Adenocarcinoma	Colonic Adenocarcinoma
M1	0%	0%	0-0.4%	0%
M2	0.03%	0%
M3	9%	0.02%
Sm1	15-20%	200 μm 1.9% (if lesion is < 2 cm)	up to 500 μm < 3%	1000 μm < 1%
Sm2		10% without risky signs 33% with risky signs	~20%	6%
Sm3		10% without risky signs 33% with risky signs	~20%	14%

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Author

Raymond E Kim, MD Associate Professor of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine; Head, Division of Gastroenterology and Hepatology, University of Maryland Midtown Campus

Raymond E Kim, MD is a member of the following medical societies: American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Coauthor(s)

Varun Kesar, MD Assistant Professor of Medicine, Associate Program Director of Gastroenterology Fellowship Program, Virginia Tech Carilion School of Medicine

Varun Kesar, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Kurt E Roberts, MD Associate Professor, Division of Bariatric and Minimally Invasive Surgery, Department of Surgery, Yale University School of Medicine; Chair, Department of Surgery, Saint Francis Hospital, Trinity Health of New England Medical Group

Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoscopic and Robotic Surgeons

Disclosure: Nothing to disclose.

Additional Contributors

Bruce D Greenwald, MD Professor of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine

Bruce D Greenwald, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Matthew Hudson, MD Fellow, Department of Gastroenterology and Hepatology, University of Maryland Medical System

Disclosure: Nothing to disclose.

Fariha H Ramay, MD, MBA Advanced Therapeutic Endoscopy Fellow, Gastroenterology and Hepatology Fellow, Division of Gastroenterology and Hepatology, University of Maryland Medical Center, University of Maryland School of Medicine

Fariha H Ramay, MD, MBA is a member of the following medical societies: American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, Women in Interventional Endoscopy

Disclosure: Nothing to disclose.

Babak Torabi Sagvand, MD Fellow, Division of Gastroenterology and Hepatology, University of Maryland Medical Center

Babak Torabi Sagvand, MD is a member of the following medical societies: American College of Gastroenterology, American Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

William R Brugge, MD Professor of Medicine, Harvard Medical School; Director, Gastrointestinal Endoscopy Unit, Massachusetts General Hospital

William R Brugge, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Federation for Clinical Research, American Gastroenterological Association, American Pancreatic Association, American Society of Gastrointestinal Endoscopy, and Crohns and Colitis Foundation of America

Disclosure: RedPath Grant/research funds Consulting

Rabindra Watson, MD Clinical Instructor, Interventional Endoscopy Services, Division of Gastroenterology, University of California, Los Angeles, David Geffen School of Medicine

Rabindra Watson, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, and American Society of Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Acknowledgments

Medscape Reference thanks Dawn Sears, MD, Associate Professor of Internal Medicine, Division of Gastroenterology and Hepatology, Scott and White Memorial Hospital; and Dan C Cohen, MD, Fellow in Gastroenterology, Scott and White Hospital, Texas A&M Health Science Center College of Medicine, for assistance with the video contribution to this article.

Sections Endoscopic Mucosal Resection (EMR) and Endoscopic Submucosal Dissection (ESD)
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Periprocedural Care
Technique
Medication
Laboratory Medicine
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Endoscopic Mucosal Resection (EMR) and Endoscopic Submucosal Dissection (ESD) Periprocedural Care

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