EMR

EMR (Endoscopic Mucosal Resection):

This technique is used to remove certain superficial neoplasms of the lumenal GI tract, inclusive of the esophagus, stomach, duodenum/small bowel, and colorectum. Lesions include Barrett’s esophagus with dysplasia and intramucosal cancer, superficial esophageal squamous cell carcinoma, gastric adenomas or dysplasia in intestinal metaplasia, certain superficial subepithelial tumors including symptomatic or high risk hyperplastic and fibroid hyperplastic polyps and pancreatic rests, sporadic duodenal/small bowel adenomas and colorectal adenomas. This technique is also utilized for endoscopic ampullectomy for ampulla neoplasms/adenoma in conjunction with ERCP with the hope of preventing the patient from major surgery with Whipple’s operation once there is no evidence of invasive cancer.

Sometimes this technique is employed with a hybrid deep dissection technique, particularly for large lesions in difficult locations and associated with fibrosis.

Below are some case examples of endoscopic mucosal resection (EMR):

Case 1: Wide field EMR of giant sigmoid colon polyp

1-Wide field EMR of giant sigmoid TA

This is a case of a giant lumen filling hemi-circumferential lobular and bulbous 8 cms type 0-ls; 0-lla polyp. The lesion was removed by debulking and widefield piecemeal EMR requiring resection in retroflexion of the anal/proximal aspect of the lesion which was obscured behind a haustral fold. Lesion under white light inspection(upper left image). Final appearance after wide-field EMR incorporating more than half of the circumference of this segment of mucosa ( forward view. upper right image, retroflexed view, lower left image). Piecemeal specimen retrieved (lower right image). No post-procedure complications. Final pathology reveals tubulovillous adenoma with foci of high-grade dysplasia and resection base includes submucosa.


Case 2: Wide field EMR of flat laterally spreading granular lesion

This is a case of a large 2.5 cm type 0-lla laterally spreading granular polyp in the proximal descending colon under high definition wight light and NBI (upper left and middle images); endoscopic appearance after during submucosal injection with a special premixed solution (upper right image). Cap-assisted piecemeal EMR  (bottom three images); appearance after complete wide field resection incorporating a few millimeters of normal lateral mucosa. There were no post-procedure complications and final pathology reveals tubular adenoma without any high-grade dysplasia.


Case 3: EMR of laterally spreading granular lesion in the cecum

This is a case of a 2 cms type 0-lla laterally spreading granular lesion type in the cecum, high definition white light and NBI (upper left, middle and right images), further characterization polyp and it’s margins appearance under high definition white light and NBI after submucosal injection and adequate lift with special pre-mixed submucosal injection solution (lower left and middle images) and endoscopic appearance after cap assisted piecemeal EMR (lower right image). In this case, the mucosal defect was not closed and non-bleeding exposed submucosal vessels in the thin layer were left intact without coagulation to minimize the risk of delayed bleeding and perforation. There were no immediate or delayed post-procedure complications of subsequent follow-up. Final pathology reveals tubulovillous adenoma with a small focus of high-grade dysplasia away from the cauterized /resection margin.


Case 4: EMR of non-ampulla duodenal adenomas in a patient with FAP and prior ampulla adenoma s/p endoscopic ampullectomy.                                              

This is a case of a male patient with Familial Adenomatous Polyposis and colon cancer, s/p total colectomy who has developed ampulla and non-ampulla adenomas. He is s/p prior ERCP and endoscopic ampullectomy. Noted with two 8 and 10 mm type 0-lla and 8 mm type 0-llb adenomas in the periampullary region. Sequential EMR performed followed by clip closure (submucosal injection lift upper and lower left images; en bloc ensnarement of lifted flat lesion upper middle image; post-resection base upper right image; overlapping resection in two pieces of adjacent non-contiguous lesions;  lower middle images; clip closure of post EMR margins lower right image). Note prophylactic PD stent placed at ERCP for surveillance and biopsies of post ampullectomy site. No post-procedure complications after overnight observation and final pathology reveal tubular adenomas without high-grade dysplasia.       

 

Case 5: Wide-field Endoscopic Mucosal Resection (EMR) of non-ampllary duodenal adenoma and closure with combination X-Tack anchors and suture, and hemoclips.   

   

This is a case of a middle-age female noted with with this sporadic adenoma during diagnostic endoscopy for non-specific upper abdmoinal pain/discomfort, biopsies of the lesion revealed tubulovillous adenoma with high grade dysplasia. She was subsequently referred for consideration for endoscopic resection. Pre-resection EUS revealed lesion was confined to the muosa and lamina propria layers and with an intact submucosa and deep players and no surrounding lymphadenopathy. The lesion was characterized as a type IIa+IIc lesion with supsected pseudodepression given no evidence of extension into an intact submucosa layer. Wide field piecemeal EMR was performed in 3 pieces and the defect was closed with a combination of X-Tack device (with 4 anchors and 3-0 prolene suture) followed by an additional 3 hemoclips for complete closure. No post procedure adverse events with overnight hospital observation and at 2 weeks follow up. Final pathology revealed tubulovillous adenoma with foci of high grade dysplasia away from any cautery margins.

Case 6: Wide field EMR of a non-ampullary sporadic duodenal adenoma in distal descending duodenum and X-Tack closure.

Case of young femal in her 4th decade. Noted with adenomatous lesion on PillCam video capsule endoscopy study as additional work up for iron deficiency anemia and after pior endoscopic evaluation, EGD and colonoscopy was reported unrevealing. This lesion was noted in the distal descending duodenum on the posteriomedial wall and characterized as a 20 mm type 0-lla + llb lesion, Kudo pit pattern type IV. Wide field piecemeal EMR was performed successfully and exposed large caliber submucosal vessels were coagulated followed by complete closure of post resection defect without any intraprocedure or post procedure adverse events.

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 Case 7: ERCP with En bloc endoscopic ampullectomy and prophylactic pancreatic stent placement.

Case of young female in late 30’s referred for endoscopic ampullectomy after noted with polypoid lesion in 2nd duodenum during diagnostic endoscopy for non specific abdominal pain and indigestion not responsive to PPI. Pathology of diminutive specimens from biopsies reported adenomatous tissue. Follow up EUS revealed polypoid ampulla and no intraductal or submucosal extension and there were no associated pathologic dilation or variant pancreaticobiliary ductal anatomy. ERCP and en bloc endoscopic ampullectomy was performed successfully and without any adverse events. Final pathology reported R0 resection of a hamartomatous polypy of Peutz-Jeghers type. Patient subsequently underwent additional diagnostic evaluation and referral for genetic testing to exclude Peutz-Jeghers Syndrome.

 

Case 8: Endoscopic Ampullectomy and ERCP for large ampulla adenoma.

A female patient referred with mild obstructive jaundice and dilated bile duct who was noted with a large ampulla lesion concerning for malignancy and inability to find bile duct orifice at attempted ERCP by referring endoscopist.

Follow up endoscopy/EUS reveals a 2.5 cm ampullary adenoma with concerning surface pattern features but no intraductal extension or submucosal invasion. ERCP was performed and revealed no filling defects in CBD or PD. Endoscopic ampullectomy was performed en bloc successfully followed by biliary and pancreatic sphincterotomy and placement of a pigtail prophylactic pancreatic duct stent. The post-ampullectomy resection margins were further ablated with APC to address any residual microscopic adenoma. Final pathology reveals tubular adenoma with foci of high-grade dysplasia but no invasive cancer. The lateral margin was clear within 1.5 mm of the cauterized margin on the specimen. 

      

Case 9: Mid-Esophagus Squamous Cell Superficial Cancer, Iodine Chromoendoscopy, and EMR

                                             

This is a case of an 82-year male with incidental finding of aberrant mucosa during diagnostic EGD for indigestion/reflux-related symptoms. Biopsies reported “severe” dysplasia on the limited specimen. Given concern for at least HGD or possible early squamous cell carcinoma, he was referred for further evaluation. Detailed endoscopic evaluation was performed with NBI and near focus in addition to chromoendoscopy with Lugol’s iodine, further defining and demarcating the dysplastic lesion as a flat granular lesion and focal superficial ulceration from the prior biopsy site. Given significant esophageal spasm with limited visualization, instead of ESD, Cap assisted EMR was meticulously performed in a contiguous fashion in two pieces sequentially. Final pathology revealed multifocal HGD (superficial T1a cancer) with clear deep and lateral margins on both specimens when oriented for prior pre-marking.

 

Case 10: Widefield EMR of large sigmoid colon tubular adenoma.

 

Case of a large lobular 4 cm type 0-Is + IIa tubular adenoma in the sigmoid colon extending behind a thick haustral fold in a relatively fixed segment of the sigmoid colon. ESD was felt to be too technically difficult and with increased risk of complication given limited visualization of the entire lesion and inability to retroflex in this segment of the colon. Therefore, wide-field piecemeal EMR was pursued incorporating a wide margin of normal mucosa to ensure complete resection. This was achieved with success, removing the lesion in six large pieces.  Given the large size of the post EMR defect, and relative fixity of the colon, closure of the defect was not attempted. The patient was discharged home the same day and no adverse events were reported with follow up phone call. Final pathology revealed tubular adenoma without any HGD. 

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