Endoscopic resection of giant fibrovascular esophageal polyps
Marc A. WardKristin W. BeardEzra N. TeitelbaumAhmed SharataChristy M. DunstLee L. SwanströmKevin M. Reavis
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Keywords:
Submucosa
Endoscopic mucosal resection
Endoscopic Ultrasound
Esophageal disease
Introduction: Submucosal injection of lifting solutions is essential for both endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). In mucosal resections, a lifting solution is injected into the submucosal layer to separate the submucosa from muscularis propria to facilitate resection of the targeted lesion. ORISETM gel (Boston Scientific) is one of the lifting solutions that was recently approved by the Food and Drug Administration in 2018. While ORISETM gel has become the popular solution, there is a concern that it could affect histologic findings. Here we report a foreign-body reaction associated with ORISETM gel injection. Case Description/Methods: A 72-year-old male with a history of Barrett’s esophagus was first found to have duodenal adenoma in the 3rd portion in 2017. 4 years later the patient was found to have polypoid tissue in the 2nd portion of the duodenum. Endoscopic mucosal resection (EMR) was attempted and the tissue was lifted by submucosal injection of 4 mL ORISETM gel, however, the procedure was aborted because the center of the polyp was fixed and could not be lifted. Biopsies were taken with cold forceps which showed duodenal adenoma without evidence of dysplasia. 65 days later, the patient underwent repeat esophagogastroduodenoscopy (EGD) to remove the lesion. ORISETM gel injection was attempted, however, the lesion could not be lifted due to severe fibrosis thus hybrid EMR was used to excise the lesion and 25 mm of mucosa was resected. Pathologic examination revealed fragments of adenoma. In addition, submucosa showed foreign material with associated foreign giant cell reaction, consistent with the site prior to the procedure. Discussion: In this case, we report a foreign giant cell reaction followed by ORISETM Gel use. The foreign body cell reaction occurs when particles are large (sizes > 10 μm) enough so that macrophages induce the foreign body giant cell formation to degrade the material. These changes can be seen as early as 3 weeks later and also seen as late as 5 months later. One of the biggest advantages of ORISETM gel is that it is a long-lasting mucosal lift but this may have backfired. Given the severe foreign body reaction into the submucosal layer, the lesion needs to be completely removed after injection of ORISE. Also, longer-term observation is needed to ascertain whether histologic changes affect subsequent mucosal resection.
Submucosa
Endoscopic mucosal resection
Muscularis mucosae
Esophagogastroduodenoscopy
Submucosal glands
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In this issue of Journal of Clinical Gastroenterology, Kodashima et al1 describe the techniques of endoscopic submucosal dissection (ESD). By now, most endoscopists in the United States are familiar with endoscopic mucosal resection (EMR) for the treatment of early cancers of the gastrointestinal tract, and many of us perform EMR in our endoscopic practice.2 The term “early cancer of the gastrointestinal tract” signifies that the cancer is limited to the mucosa or submucosa and is at no risk or very low risk of lymph nodal metastasis and with excellent overall prognosis. EMR has rapidly become a therapeutic alternative for the management of early gastrointestinal cancers in selected patients. However, EMR has its limitations, and even in the best hands, the size of the lesion remains critical. In general, any lesion more than 2 cm in maximal dimension is difficult to remove en bloc by EMR. En bloc resection, however, is crucial for reliable histopathologic staging, and local recurrence rates are higher with piecemeal resection. Also, ulcerated lesions (type 0–III) very often cannot be completely removed by EMR.3 To obviate these shortcomings of EMR, several groups of investigators in Japan have devised the technique of ESD. In short, ESD uses specially devised electrocautery knives that allow removal of the lesions en bloc regardless of size, shape, coexisting ulcer, and location. ESD, similarly to EMR, involves chromoendoscopy for better delineation of the lesion, lifting the lesion with submucosal injection and mucosal incision, but unlike EMR, it additionally involves careful dissection of the submucosa with specialized electrocautery devices. Several electrocautery devices are commercially available, including the flexknife (KD-630L; Olympus, Japan); IT knife (KD-610L; Olympus), which has a small ceramic ball at the tip of the needle, functioning as an insulator; hook knife (KD-620LR; Olympus), whose top is right-angled and 1 mm in size to hook the submucosal tissue; a precut needle knife combined with a transparent hood (DH-15GR; Fujinon, Japan), the tip of whose ST hood is tapered to 7 mm at the opening; and triangle-tipped knife (KDL-640 L, Olympus).4 With use of a stinker or a magnetic anchor device, traction-assisted dissection methods have also been described.5,6 Submucosal injection and appropriate lifting of the lesion are crucial to determine the correct plane of dissection. Although saline injection is commonly used, particularly during ESD performed with the IT knife, more investigators are using a combination of different concentrations of glycerol and hyaluronic acid, often with a drop of coloring agent (such as indigo carmine) to color the submucosa for easy endoscopic identification. The most common complications of ESD, obviously, are bleeding and perforation, and there are encouraging data from several groups that a good proportion of these complications can be managed with a combination of endoscopic therapy and conservative measures so that surgery may be avoided. Is ESD a procedure that is going to come and go away? That possibility seems unlikely. EMR, backed by substantial data on excellent outcomes with respect to rate of curative resection and improved quality of life, is already recognized as a viable alternative option for many patients with early gastrointestinal cancers. ESD is but a natural extension of the technique of EMR. There is no doubt that ESD requires more operating time and better endoscopic skills and that it has more potential for complications. Continued improvement in the technique of ESD will surely occur with improved endoscopic designs and innovative endoscopic accessories. Also, several questions remain to be answered. Is ESD really as safe and effective as it appears to be in the hands of experts? Would long-term data support the notion that recurrences are indeed less common with ESD compared with EMR? In case recurrent lesions develop, is it feasible and safe to repeat ESD in the same area of the gastrointestinal tract? What is the role of different ablative therapies in combination with ESD? Also, in the absence of controlled comparative data, how would one choose one technique of ESD over another with respect to different endoscopic devices and solutions for submucosal injection? It is clear that by no means have the techniques of ESD yet been perfected, and even in Japan continual modifications are being reported. It is unlikely that ESD will become a common endoscopic procedure in the near future, but we will surely watch this exciting development in therapeutic endoscopy with keen interest.
Submucosa
Endoscopic mucosal resection
Chromoendoscopy
Endoscopic submucosal dissection
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Duodenal carcinoids are a rare form of neuroendocrine tumors, and tend to invade the submucosa during the early stage.Endoscopic treatment is generally recommended for duodenal carcinoids less than 10 mm in diameter.Although a few reports have described the use of endoscopic resection of duodenal carcinoids, there are no published studies on endoscopic mucosal resection with circumferential mucosal incision (EMR-CMI).We performed EMR-CMI for 5 cases of duodenal carcinoids in the duodenal bulb.The mean tumor diameter was 4.6 ± 1.8 mm.Although all of the tumors were located in the submucosa, R0 resection was performed without complication in each case.EMR-CMI may thus be a safe and effective treatment for duodenal carcinoids less than 10 mm in diameter.
Duodenal bulb
Endoscopic mucosal resection
Submucosa
Duodenoscopy
Endoscopic treatment
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Endoscopic mucosal resection (EMR) has evolved to become the widely adopted technique for managing intermediate and large non-pedunculated colorectal neoplasia. Several methods of EMR have been described in the literature. Broadly, the techniques can be classified into those that are performed with submucosal injection and those with suction alone [1]. The critical part of EMR is to resect the affected mucosa and submucosa while avoiding injuring the muscularis propria. The simplest and easiest way to prevent entrapping the muscularis propria is to inject fluid into the submucosal layer to expand it. Adequate expansion of the submucosa allows for a safe margin for resection of the diseased mucosa. By adopting the inject-lift-and-cut technique, EMR can be performed safely in any part of the gastrointestinal tract [2].
Submucosa
Endoscopic mucosal resection
Muscularis mucosae
Lamina propria
Resection margin
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Background and Study Aims: One of the major complications of endoscopic mucosal resection (EMR) for gastrointestinal tumors is perforation, and the most effective way of preventing perforation is to elevate the lesion sufficiently by endoscopic injection of fluid into the submucosa. Materials and Methods: In order to compare the lesion-lifting properties of several different solutions, 1 ml of each of the following solutions was injected into the submucosa of the resected porcine stomach: normal saline, 3.75 % NaCl, 20 % dextrose water, 10 % glycerin with 0.9 % NaCl plus 5 % fructose, and two sodium hyaluronate (SH) solutions.
Submucosa
Endoscopic mucosal resection
Sodium hyaluronate
Perforation
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Submucosa
Endoscopic mucosal resection
Endoscopic submucosal dissection
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Duodenal carcinoids are a rare form of neuroendocrine tumors, and tend to invade the submucosa during the early stage. Endoscopic treatment is generally recommended for duodenal carcinoids less than 10 mm in diameter. Although a few reports have described the use of endoscopic resection of duodenal carcinoids, there are no published studies on endoscopic mucosal resection with circumferential mucosal incision (EMR-CMI). We performed EMR-CMI for 5 cases of duodenal carcinoids in the duodenal bulb. The mean tumor diameter was 4.6 ± 1.8 mm. Although all of the tumors were located in the submucosa, R0 resection was performed without complication in each case. EMR-CMI may thus be a safe and effective treatment for duodenal carcinoids less than 10 mm in diameter.
Submucosa
Duodenal bulb
Endoscopic mucosal resection
Endoscopic treatment
Duodenoscopy
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Gastric carcinoid tumors (GCTs) often extends into the submucosa, and are therefore difficult to resect completely by using conventional endoscopic mucosal resection (EMR). Endoscopic submucosal dissection (ESD) allows en bloc resection of submucosal gastrointestinal lesions. Therefore, ESD may be a feasible method for complete resection of GCT. Our purpose is to clarify the usefulness of ESD for treatment of type I GCT.Between 1998 and 2011, EMR or ESD was performed for 13 lesions in 12 patients with type I GCTs. Among the 13 GCTs, 6 were resected using EMR, and 7 were removed using ESD.All lesions were histologically classified as Grade 1. The depth of invasion was the mucosa for 1 lesion and the submucosa for 12 lesions. The horizontal margins of excision were negative for all lesions; however, the vertical margins were positive in 4 lesions (66.7%) in the EMR group and no lesions (0%) in the ESD group.The results of this study suggest that ESD for small type I GCT is better to achieve complete resection than conventional EMR. ESD would be an effective technique for the treatment of small type I GCT.
Submucosa
Endoscopic submucosal dissection
Endoscopic mucosal resection
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Endoscopic mucosal resection
Submucosa
Polypectomy
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