Endoscopic Mucosal Resection (EMR)
Endoscopic mucosal resection (EMR) is another treatment for Barrett’s esophagus with dysplasia.
EMR can be used to remove small nodules and lesions or to remove flat-appearing BE. The pieces removed are 15-20 mm in size, compared to regular esophageal biopsies, which are about 3-4 mm in size. EMR can be used to take out one piece of mucosa at a time (like a single nodule). Multiple EMRs can also be done in one area to resect a larger area of mucosa (like a flat area known to have a lot of HGD). In some centers, larger areas of BE (think 3 cm or larger pieces) have been removed, also called ‘en bloc’ resection or ‘total endoscopic resection’. In the US, EMR is often used with other techniques (such as ablation) for management of BE with dysplasia.
There are several methods used to perform EMR. Here are a few:
Band mucosectomy – a small plastic cap is placed on the tip of the endoscope. The lining of the esophagus is sucked into the cap and a small rubber band is placed around the tissue. The tissue looks like a polyp after the rubber band is in place. A snare (like a lasso) can then be used to cut off the polyp, typically using some electric current to cut the tissue loose. The tissue is collected, pinned to a piece of foam to keep it flat, and sent to pathology for examination.
Cap and snare – a plastic cap is attached to the tip of the endoscope. Fluid, such as sterile saline, may be injected under the mucosa of the esophagus, raising it up. The esophageal mucosa is then sucked into the cap and a metal snare is placed around the tissue. When the snare is closed, an electric current (cautery) is used to cut the tissue. The piece is collected and sent to pathology.
En bloc resection – Multiple EMRs are performed, with the goal of resecting every bit of BE tissue in an area. Large (a few centimeters) areas of BE may be resected during one procedure. This is less commonly performed in the US, but is popular in some areas of Europe and Asia.
Endoscopic submucosal dissection (ESD) – First used in the stomach to remove small gastric cancers in Asia, ESD has also been used in the esophagus to resect areas of BE with dysplasia. The area to be resected is marked with cautery, and special tools are used to ‘dissect’ (peel up the mucosa) from the underlying submucosa of the esophagus. Much of the research on ESD has been done in Japan and some in Europe. Special tools are typically used to perform ESD and most are not available in the US at this time.
As far as risks of EMR and complications, there are several. Resection of small areas of BE and nodules is typically successful, but only treats the area of BE where it is applied. So there may be other areas of dysplasia in the esophagus that aren’t treated with the EMR. Repeat biopsy to look for other areas of dysplasia is important. Resection of larger areas of BE during one procedure is more challenging, but can be done. The potential complications of EMR include bleeding and perforation. The risk of bleeding is higher than with a standard biopsy as the pieces are larger, but can typically be treated by applying small metal clips to the bleeding areas. Perforation of the esophagus (making a hole) can also occur with EMR and the rate of perforation is about 1%. Strictures, or narrowing of the esophagus by scar tissue, can also occur. This is less common with small areas of EMR, but can occur with circumferential resection or large areas of EMR. Strictures can be treated with esophageal dilation (stretching with a balloon or rubber tube) but may take several dilations to be treated completely. For EMR of large areas, making sure that all the dysplastic BE tissue has been resected is important. Residual areas of BE between EMR sites should be re-biopsied and resected if possible. Some people will have discomfort after EMR, particularly if multiple pieces of the esophageal lining are removed during the procedure, but this typically improves in a few days.
So, EMR is one of several methods of treating BE with dysplasia. It often gets used in combination with other therapies, like ablation. As with all treatments for BE, surveillance endoscopy is needed.
Seewald S, et al. Total endoscopic resection of Barrett’s esophagus. Endoscopy 2008;40:1016-1020.
Pouw et al. Endoscopic resection of early oesophageal and gastric neoplasia. Best Practice & Research Clinical Gastroenterology 2008;(22):929-943.
posted by Kerry Dunbar, MD