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Create a Free AccountProcedures - Endoscopic mucosal resection (EMR)
Endoscopic resection of GI stromal tumor using full-thickness resection device: tips and tricks
Gastrointestinal stromal tumor (GIST) is the most common type of subepithelial lesion (SEL) in the stomach. Management of gastric GISTs varies by size. While all gastric GISTs ≥2 cm should be resected, the need to resect gastric GISTs <2 cm is still controversial given that surgical resection may be too aggressive for small, low-risk GISTs. On the other hand, evidence suggests that even <2-cm GISTs can metastasize.1 In fact, the Canadian guidelines suggest that even GISTs <1 cm should be excised because of the risk of metastases.Underwater EMR for the diagnosis of diffuse infiltrative gastric cancer
A 75-year-old woman experienced nausea 7 months prior and had lost 9 kg over 3 months. She was referred to the university hospital for further examination. A CT scan showed circumferential wall thickening of the stomach. Endoscopic examination revealed markedly enlarged folds, redness, and poor extension of the gastric lumen. Advanced infiltrative gastric cancer was suspected. However, endoscopic forceps biopsy specimens did not reveal adenocarcinoma. Endoscopic examination and the forceps biopsy were repeated twice during the next 6 months.Combination of rubber band traction and partial injection for effective under-gel endoscopic mucosal resection of an ileocecal valve lesion
Neoplasms on the ileocecal valve (ICV) extending into the terminal ileum complicate EMR and endoscopic submucosal dissection (ESD), resulting in lower complete-resection rates; this leads to tumor recurrence.1,2 ESD for ICV neoplasms, although feasible and effective, is time-consuming and not yet established as a standard procedure.2Wide-field endoscopic mucosal resection of laterally spreading rectal tumors using a multiband ligation endoscopic mucosal resection technique
Advanced tissue resection techniques such as EMR and endoscopic submucosal dissection (ESD) have been established as therapeutic options for the management of advanced mucosal neoplasia of the colon. EMR has been found to safely and effectively remove sessile or flat neoplasms confined to the superficial layers of the GI tract.1Gel immersion endoscopy-facilitated endoscopic mucosal resection of a superficial nonampullary duodenal epithelial tumor: a novel approach
Endoscopic resection of superficial nonampullary duodenal epithelial tumors (SNADETs) is considered highly difficult because of the technical challenges posed by the complex anatomic features of the duodenum.1-3 Underwater endoscopic mucosal resection (UEMR), a water immersion method, results in high resection and low adverse event rates.1-3 However, continuously maintaining water in the lumen is difficult.Rubber band-assisted closure of a mucosal defect following duodenal EMR
EMR of large duodenal adenomas is a technically challenging procedure. It carries a particularly high risk of perforation (5 % -10%) because of its relatively thin and fixed wall and delayed bleeding (15%) due to its rich vascular supply.1 Systematic closure of mucosal defects after duodenal endoscopic resection has been found to significantly reduce the risk of delayed adverse events (AEs) by 80%, specifically the risk of delayed bleeding and perforation.2 However, owing to the fixed retroperitoneal descending duodenum, apposition of the 2 mucosal edges is not always feasible, making closure using standard clips challenging.Endoscopic hemostatic spray for uncontrolled bleeding after complicated endoscopic mucosal resection or endoscopic submucosal dissection: a report of 2 cases
There is a significant bleeding risk after gastric endoscopic submucosal dissection (ESD) and EMR cases. This case series describes the use of an endoscopic hemostasis spray, which is not typically used to treat this type of bleeding, after multiple attempts with other modalities failed.GI endoscopic submucosal dissection using a calibrated, small-caliber-tip, transparent hood for lesions with fibrosis
To date, various methods to manage severely fibrotic lesions encountered during endoscopic submucosal dissection (ESD) have been described. In this regard, the method of dissecting the submucosa on both sides of the fibrotic area before dissecting the severely fibrotic part has been reported to be beneficial.1,2 In particular, the pocket-creation method (PCM) is considered to be a useful method for adding adequate traction to the fibrotic area by using a small-caliber-tip, transparent (ST) hood with a tapered tip and allowing the muscles to be approached in parallel.Underwater endoscopic mucosal resection of a rectal adenoma in the nondistensible rectum from severe fecal incontinence
In a patient with severe fecal incontinence, polypectomy of rectal adenomas may be difficult if the patient cannot retain gas in the rectum. Existing literature does not include reports of the optimal polypectomy technique in these patients. We describe a challenging case of difficult polypectomy in the nondistensible rectum from severe fecal incontinence (Video 1, available online at www.giejournal.org ).Over-the-scope-clip treatment for perforation of the duodenum after endoscopic papillectomy
Endoscopic papillectomy is an alternative to surgery for tumors of the ampulla of Vater. Adverse effects of the procedure, however, include pancreatitis, bleeding, and papillary stenosis, as well as occasional perforations,1 which are sometimes challenging to treat endoscopically. A novel endoscopic closure device, the Over-the-Scope Clip (OTSC; Ovesco Endoscopy, Tübingen, Germany) System, has increased the ability of the therapeutic endoscopist to close gastrointestinal luminal defects and treat gastrointestinal bleeding.Endoscopic unroofing and mucosal resection for a large colonic lipoma with intussusception: an effective hybrid technique
Lipomas account for 4% of benign subepithelial tumors of the GI tract and are found mainly in the colon (65%-75%).1 Colonic lipomas are often found incidentally during colonoscopy and are often asymptomatic and <20 mm in size and therefore do not require routine colonoscopy or treatment.2 However, in rare cases, colonic lipoma may grow to the point of being symptomatic.Use of a rigidizing overtube to complete an incomplete colonoscopy
The successful completion of colonoscopy can be limited by endoscopist skill, bowel preparation, and looping.1 A variety of different techniques are available to manage looping, such as abdominal splinting, use of variable-stiffness colonoscopes, and reduction maneuvers.1-3 If cecal intubation remains difficult despite these maneuvers, overtube-assisted colonoscopy may help achieve this goal. This may include the use of single-balloon or double-balloon enteroscopy, spiral enteroscopy, or colonic overtubes.A case of duodenal polyp at superior duodenal angle successfully treated by cap-assisted endoscopic mucosal resection
Recent studies have demonstrated an increase in endoscopic treatments for duodenal polyps.1,2 However, endoscopic treatment for duodenal polyps is technically challenging because of the high risk of severe adverse events, such as perforation and bleeding.3 Most of the cases reported to date deal with polyps located in the first and second parts of the duodenum; there are few reports of treatment for duodenal polyps at the superior duodenal angle (SDA). Endoscopic observation and resection of duodenal polyps at the SDA are extremely difficult because of the anatomical complexity and poor maneuverability of the endoscope.Salvage circumferential endoscopic submucosal dissection for refractory dysplastic Barrett’s esophagus
A 64-year-old woman initially underwent endoscopy for reflux symptoms and was found to have C7M8 Barrett’s esophagus with biopsies demonstrating high-grade dysplasia. She was referred to a tertiary esophageal center, which performed endoscopic mucosa resection.Endoscopic full-thickness resection of a stomach gastrointestinal stromal tumor using a dedicated full-thickness resection device
Endoscopic full-thickness resection (EFTR) is increasingly performed for the removal of GI subepithelial lesions (SELs). EFTR is minimally invasive compared with surgery but still can procure an adequate specimen for histologic assessment. A dedicated EFTR device (Ovesco Endoscopy, Tübingen, Germany) has been developed for the management of colorectal lesions.1 Data on its safety and efficacy for lesions in the upper GI tract are limited.2,3 In this case, we share our experience with the off-label use of a dedicated EFTR device for the removal of a GI stromal tumor (GIST) in the stomach.Delineating sessile serrated adenomas/polyps with acetic acid spray for a more accurate piecemeal cold snare polypectomy
Cold snare polypectomy (CSP) is becoming one of the therapeutic methods of choice for benign polyps in light of its time- and cost-effective properties compared with hot snare polypectomy.1 The safety and effectiveness of piecemeal CSP (pCSP) of large sessile serrated lesions (SSLs) have been studied in the past,2,3 and we have reported pCSP for SSLs without using injection.4 The method was effective, but minor bleeding around the edge of the SSL often rendered examination for remnant tumors more difficult.Colonoscopic resection of appendiceal endometriosis
Endometriosis (EM) is the presence of endometrial tissue outside the uterine cavity.1 It commonly affects women of reproductive age and results in abdominal/pelvic pain and possible infertility.1 Appendiceal EM is exceedingly rare; it constitutes approximately 3% of all GI EM and accounts for less than 1% of all EM cases.2 The appendiceal tip and body are the most frequent locations of involvement. An estimated 66% of cases affect the muscular and seromuscular layers of the appendix.2 Additionally, 33% of cases involve the appendiceal serosa.Closure of mucosal defect with a micro-ring technique: simple, cheap, and effective
Effective closure methods of mucosal leakage are a paramount tool for every endoscopist. They are crucial in reducing the need for surgery and allowing us to stretch the limits of interventional endoscopy. The aim of these videos is to share a simple and cheap solution to close large mucosal defects (Videos 1, available online at www.VideoGIE.org ).Underwater EMR of a colonic adenoma surrounded by diverticula
An 83-year-old man with positive fecal occult blood test results underwent colonoscopy, which revealed a 15-mm-diameter laterally spreading tumor surrounded by multiple diverticula at the ascending colon (Figs. 1 and 2). The lesion was a nongranular-type laterally spreading tumor, and the Japanese Narrow-Band Imaging Expert Team classification was type 2A, meaning no evidence of invasion; therefore, we performed endoscopic resection instead of surgery.Suction marking method: a novel technique to prevent overlooking of polyps detected upon endoscope insertion
It has been established that removal of adenomas reduces the prevalence and mortality of colorectal cancers.1,2 Because the miss rate of polyps in colonoscopy remains high, an appropriate approach for all polyps, even for lesions detected upon endoscope insertion, plays an important role in achieving high-quality colonoscopy.Endoscopic unroofing drainage with a needle-knife for gastric wall abscess: a rare adverse event that developed after EUS-FNA
Gastric wall abscess (GWA) is a rare adverse event of EUS-FNA. There have been a few reports of therapeutic interventions for GWA, such as EUS-guided drainage or surgical drainage. We report a case of GWA that was successfully treated by the endoscopic unroofing technique (Video 1, available online at www.VideoGIE.org ).Acetic acid spray for better delineation of recurrent sessile serrated adenoma in the colon
Sessile serrated lesions (SSLs) have a high risk of incomplete endoscopic resection.1 The benefit of using acetic acid spray has been reported for SSLs in the colon.2,3 Our previous experience has demonstrated that acetic acid spray, along with indigo carmine, is of substantial benefit for the delineation of SSLs.2 Similarly, the use of acetic acid for a single case of sessile serrated polyposis syndrome was reported and showed clinical usefulness.3Wide-field underwater EMR followed by line-assisted complete closure for a large duodenal adenoma
Duodenal adenoma has a risk of developing into cancer. En bloc resection with conventional EMR is difficult for a large lesion, whereas duodenal endoscopic submucosal dissection is associated with a high risk of perforation.1 Piecemeal underwater EMR is effective for large duodenal adenomas; however, a large mucosal defect carries a risk of delayed adverse events.2 Although complete closure after endoscopic resection can reduce adverse events,3,4 closure of a large mucosal defect with endoclips is difficult.Endoscopic resection of an unusual ampullary adenoma
A 40-year-old woman with no comorbidities presented with episodic postprandial bilious vomiting of 6 months’ duration and mild abdominal discomfort. Her liver function tests showed normal bilirubin with raised alkaline phosphatase and γ-glutamyltransferase. Abdominal US had shown dilatation of the common bile duct (CBD) and pancreatic duct (PD). She had previously undergone MRCP, which showed diffuse dilatation of the CBD, common hepatic duct, and intrahepatic biliary radicles with smooth tapering at the region of the ampulla, diffuse prominence of the main PD, and ectopic ampulla of Vater.Endoscopic management of gastroesophageal reflux disease after sleeve gastrectomy by use of the antireflux mucosectomy procedure
Sleeve gastrectomy is the most common bariatric surgery in the United States.1 However, studies have reported an increased rate of de novo GERD after surgery and high rates of new-onset cases of Barrett's esophagus.2-5
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