ESGE HEADLINE NEWS N°3

Endoscopic mucosal resection

R Lambert

Synopsis

Early cancer in the digestive-tract mucosa, as well as premalignant precursor lesions, are now often treated using endotherapy procedures. The decision on whether to carry out surgery or endoscopy is based on the morphology of the lesion (according to the Paris classification), which helps predict the risk of submucosal invasion and lymph-node invasion. Polypectomy is carried out for adenomatous polyps. Endoscopic mucosal resection is carried out for nonpolypoid neoplastic lesions. After its boundaries have been marked, the lesion is lifted by injecting saline submucosally and it is then resected with a snare.

A recently developed technique involves a circumferential incision of the full thickness of the mucosa around the lesion with a needle-knife. This en-bloc resection of a large area of the mucosal surface allows complete removal of the lesion more often than piecemeal resection in multiple fragments. Another advance has been made with dissection of the submucosa under direct vision. Endoscopic mucosal resection (EMR) with submucosal dissection is more precise and allows better control of invasion into the submucosa.

Two major complications of EMR are severe bleeding and perforation. These occur more often when the needle-knife is used. Endoscopists need to master the technique of clipping, either for hemostasis or for immediate suturing of perforations should they occur.

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References

1)	Conio M, Cameron AJ, Chak A, et al. Endoscopic treatment of high-grade dysplasia and early cancer in Barrett’s oesophagus. Lancet Oncol 2005;6:311–21. » Lancet Oncol. 2005 May;6(5):311-21.
2)	Endoscopic Classification Review Group. Update on the Paris classification of superficial neoplastic lesions in the digestive tract. Endoscopy 2005;37:570–8. » Endoscopy. 2005 Jun;37(6):570-8.
3)	Feitoza AB, Gostout CJ, Burgart LJ, et al. Hydroxypropyl methylcellulose: a better submucosal fluid cushion for endoscopic mucosal resection. Gastrointest Endosc 2003;57:41–7. » Gastrointest Endosc. 2003 Jan;57(1):41-7.
4)	Fujishiro M, Yahagi N,Kashimura K et al . Different Mixtures of Sodium Hyaluronate and Their Ability to Create Submucosal Fluid Cushions for Endoscopic Mucosal Resection. Endoscopy 2004; 36: 584-589. » Endoscopy. 2004 Jul;36(7):584-9.
5)	Inoue H, Fukami N, Yoshida T, et al. Endoscopic resection of esophageal and gastric cancers. J Gastroenterol Hepatol 2002;17:382–8. » J Gastroenterol Hepatol. 2002 Apr;17(4):382-8.
6)	Kudo S, Kashida H, Tamura T, et al. Colonoscopic diagnosis and management of nonpolypoid early colorectal cancer. World J Surg 2000;24:1081–90. » World J Surg. 2000 Sep;24(9):1081-90.
7)	Kudo S, Tamegai Y, Yamano H, et al. Endoscopic mucosal resection of the colon: the Japanese technique. Gastrointest Endosc Clin N Am 2001;11:519–35. » Gastrointest Endosc Clin N Am. 2001 Jul;11(3):519-35.
8)	Lambert R. Treatment of esophagogastric tumors. Endoscopy 2003;35:118–26. » Endoscopy. 2003 Feb;35(2):118-26.
9)	Makuuchi H. Endoscopic mucosal resection for mucosal cancer in the esophagus. Gastrointest Endosc Clin N Am 2001;11:445–8. » Gastrointest Endosc Clin N Am. 2001 Jul;11(3):445-58.
10)	Miyamoto S, Muto M, Hamamoto, et al. A new technique for endoscopic mucosal resection with an insulated tip electrosurgical knife improves the completeness of intramucosal gastric neoplasms. Gastrointest Endosc 2002;55;576–81. » Gastrointest Endosc. 2002 Apr;55(4):576-81.
11)	Ohkuwa M, Hosokawa K, Boku N, et al. New endoscopic treatment for intramucosal gastric tumors using an insulated-tip diathermic knife. Endoscopy 2001;33:221–6. » Endoscopy. 2001 Mar;33(3):221-6.
12)	Ono H, Kondo H, Gotoda T, et al. Endoscopic mucosal resection for treatment of early gastric cancer. Gut 2001;48:225–9. » Gut. 2001 Feb;48(2):225-9.
13)	Pech O, Gossner L, May A, et al. Endoscopic resection of superficial esophageal squamous-cell carcinomas: Western experience. Am J Gastroenterol 2004;99:1226–32. » Am J Gastroenterol. 2004 Jul;99(7):1226-32.
14)	Rembacken BJ, Gotoda T, Fujii T, et al. Endoscopic mucosal resection. Endoscopy 2001;33:709–18. » Endoscopy. 2001 Aug;33(8):709-18.
15)	Rösch T, Sarbia M, Schumacher B, et al. Attempted endoscopic en bloc resection of mucosal and submucosal tumors using insulated-tip knives: a pilot series. Endoscopy. 2004 Sep;36(9):788-801. » Endoscopy. 2004 Sep;36(9):788-801.
16)	Shim CS. Endoscopic mucosal resection: an overview of the value of different techniques. Endoscopy 2001;33:271–5. » Endoscopy. 2001 Mar;33(3):271-5.
17)	Suzuki H. Endoscopic mucosal resection using ligating device for early gastric cancer. Gastrointest Endosc Clin N Am 2001;11:511–8. » Gastrointest Endosc Clin N Am. 2001 Jul;11(3):511-8.
18)	Tanabe S, Koizumi W, Mitomi H, et al. Clinical outcome of endoscopic aspiration mucosectomy for early stage gastric cancer. Gastrointest Endosc 2002;56:708–13. » Gastrointest Endosc. 2002 Nov;56(5):708-13.
19)	Tsunada S, Ogata S, Ohyama T, et al. Endoscopic closure of perforations caused by EMR in the stomach by application of metallic clips. Gastrointest Endosc 2003;57:948–51. » Gastrointest Endosc. 2003 Jun;57(7):948-51.
20)	Yamamoto H, Sekine Y, Higashizawa T, et al. Successful en bloc resection of a large superficial gastric cancer by using sodium hyaluronate and electrocautery incision forceps. Gastrointest Endosc 2001;54:629–32. » Gastrointest Endosc. 2001 Nov;54(5):629-32.
21)	Yamamoto H, Kawata H, Sunada K, et al. Success rate of curative endoscopic mucosal resection with circumferential mucosal incision assisted by submucosal injection of sodium hyaluronate. Gastrointest Endosc 2002;56:507–12. » Gastrointest Endosc. 2002 Oct;56(4):507-12.
22)	Yamamoto H, Kawata H, Sunada K, et al. Successful en-bloc resection of large superficial tumors in the stomach and colon using sodium hyaluronate and small-caliber-tip transparent hood. Endoscopy 2003;35:690–4. » Endoscopy. 2003 Aug;35(8):690-4.
23)	Yamamoto H, Yahagi N, Oyama T. Mucosectomy in the colon with endoscopic submucosal dissection. Endoscopy 2005;37:764–8. » Endoscopy. 2005 Aug;37(8):764-8.
24)	Yoshikane H, Sakakibara A, Hidano H, et al. Piecemeal endoscopic aspiration mucosectomy for large superficial intramucosal tumors of the stomach. Endoscopy 2001;33:795–9. » Endoscopy. 2001 Sep;33(9):795-9.