in Barrett's esophagus was esophagectomy in surgically fit patients. This was based on historic data which showed 40% of patients with presumed HGD had ...
Endoscopic Submucosal Dissection of Barrett’s Neoplasia P Bhandari, Queen Alexandra Hospital, Portsmouth, UK r 2013 Elsevier GmbH. Open access under CC BY-NC-ND license. Received 31 July 2012; Revision submitted 31 July 2012; Accepted 23 September 2012
Abstract Nodular lesions in Barrett’s esophagus carry a high risk of invasive cancer. However, good prognostic cancers with depth of invasion no more than submucosal (SM)-1 can potentially be cured by endoscopic resection. Endoscopic submucosal dissection (ESD) enables en bloc resection of lesions larger than 20 mm, and this allows accurate histological assessment, which is mandatory for the management of patients. This case illustrates the feasibility of ESD for resection of Barrett’s neoplasia in the western setting. It illustrates the role of the distal hood and a combination of knives in improving the safety and feasibility of ESD in Barrett’s esophagus. This article is part of an expert video encyclopedia.
Keywords Barrett’s esophagus; Endoscopic submucosal dissection; Standard endoscopy; Video.
Video Related to this Article Video available to view or download at doi:10.1016/S22120971(13)70027-X
Materials and Methods
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Knives: 2-mm Dual knife (Olympus UK Ltd, Southend-onSea, UK); Hook knife (Olympus UK Ltd, Southend-on-Sea, UK); 4-mm distal hood (Olympus UK Ltd, Southend-onSea, UK). VIO 300 Erbotome (ERBE, Elektromedizin GmbH, Waldhoernlestrasse, Tuebingen, Germany) was used as a diathermy unit; Endocut-I was used for mucosal incision; and forced coagulation mode at 50 W was used for submucosal dissection. Injection fluid: Combination of a colloid called Gelofusin; B. Braun Medical, Sheffield, UK (500 ml), adrenaline; Mercury Pharma, Croydon, UK 1:10 000 (2 ml), and 0.8% indigo carmine; American Regent, New York, NY, USA (5 ml).
Background and Endoscopic Procedures The traditional management of high-grade dysplasia (HGD) in Barrett’s esophagus was esophagectomy in surgically fit patients. This was based on historic data which showed 40% of patients with presumed HGD had invasive cancer on esophagectomy specimen.1–3 This data is old and not relevant to current practice. However, the 40% figure still remains relevant to a particular type of Barrett’s neoplasia. Barrett’s neoplasia can be flat or nodular. The risk of invasive cancer is very low in flat neoplasia, at approximately This article is part of an expert video encyclopedia. Click here for the full Table of Contents.
Video Journal and Encyclopedia of GI Endoscopy
3%,4 but remains very high in nodular dysplasia, reaching the historic figure of 40%. It is therefore very important for an endoscopist to assess each lesion on its own merits. The advent of band ligation technique and radiofrequency ablation (RFA) has simplified the management of Barrett’s neoplasia, which is in many ways good. However, in simplification lies the danger; whereas band ligation is an extremely effective technique in treatment of flat neoplasia,5 the endoscopist should be very cautious when using this technique for nodular dysplasia. Experienced experts in this field can differentiate a dysplastic nodule from a presumed dysplastic nodule harboring invasive cancer. The latter lesion could have a cancer invading deep into the submucosa or even going all the way to the muscle.6,7 The banding technique in such settings might resect through the tumor and leave residual cancer behind, or the suction used during the banding might bring the muscularis propria into the band with untoward consequences. The lesion shown in the video of this article is from an 80-year-old otherwise fit lady with no comorbidities. She had a very large segment of Barrett’s, from 20 to 30 cm with a 10-cm hiatus hernia below it. The nodule was situated at 26 cm and measured 25 mm in size. It was discovered at a routine gastroscopy, and biopsy showed HGD. Gastroscopy was repeated and further biopsies showed suspicion of invasive cancer. Endoscopic ultrasound and computed tomography scan did not show any cause for concern. The patient was then referred to the author’s center and was evaluated with acetic acid-assisted chromoendoscopy. This showed a nodule with a IIc depressed area, which raised a strong suspicion of submucosal (SM) invasive neoplasia. The decision was to resect it in one piece to achieve accurate histological staging. Given the large size of the nodule, it was not possible to resect it in one piece by either the banding technique or cap and snare technique. As the center had expertise in gastric and colonic ESD, a decision to resect it by ESD technique was made. The team was comforted by the large hiatus hernia as that would allow operation in retroflexed position to resect the
http://dx.doi.org/10.1016/S2212-0971(13)70027-X
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Endoscopic Submucosal Dissection of Barrett’s Neoplasia
far (distal) side of the lesion. The procedure was performed under general anaesthetic and a combination of knives were used to help resect the tricky areas. The distal transparent hood shown in the video of this article was essential to get into and maintain the scope in the correct plane during submucosal dissection. It took 90 min to achieve a complete resection. The post-ESD histology revealed an SM-1 invasive cancer with clear, deep, and lateral margins. The site was reevaluated at 8 weeks and showed a very healthy and subtle scar with no narrowing and, surprisingly, no neosquamous epithelium. The patient subsequently underwent RFA ablation of the residual Barrett’s esophagus.
00:56–01:45 (Submucosal injection)
Key Learning Points/Tips and Tricks
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Endoscopists involved in the treatment of Barrett’s neoplasia should have very good skills and knowledge in lesion assessment. Use of acetic acid allows very good assessment of the surface patterns and lesion margins. Colloid solution mixed with indigo carmine and adrenaline improves the safety of ESD. ESD in the esopahgus should only be performed after acquiring expertise in this technique in stomach and rectal lesions. Use of a transparent hood in front of the endoscope allows good access into the submucosal plane and improves the safety of the submucosal dissection. A combination of knives can help improve the feasibility and safety of ESD in the western setting.
these markings are continued all around to pre-mark the resection zone. Once the marking is achieved, a strategically planned submucosal injection is performed to elicit the lifting sign in an area very close to the suspected site of deep invasion as shown here. After a little delay, submucosal lift begins to appear and this is very important as it confirms the feasibility and safety of endoscopic resection in the absence of which the procedure would have been aborted at this stage. Further injections are then performed to achieve a good submucosal fluid cushion on the oral side of the lesion as shown here.
01:46–02:33 (Mucosal incision & Submucosal dissection)
A dual knife is now being inserted through the biopsy port of the endoscope to start the mucosal incision as shown here. The incision is started on the oral side of the lesion and continued until a mucosal flap can be lifted to allow access to the submucosal plane. The distal hood plays a crucial role here in lifting the mucosal flap, allowing the scope to be inserted into the submucosal space and, most importantly, in maintaining the orientation of the scope in the correct plane as shown here with the lesion at the top and muscle layer at the bottom. Small, gentle strokes of the knife are then delivered in a horizontal plane to incise the submucosal fibers.
2:34–2.51 (Further Submucosal dissection)
During this phase of endoscopic submucosal dissection (ESD), it is important to be aware of the planes, which are constantly changing, as shown here with the lesion on the left and the muscle on the right so the endoscopist is now cutting the submucosal fibers in a vertical plane with the knife always moving away from the muscle.
2:52–03.24 (Bleeding & Hemostasis)
As the submucosal fibers are incised, inadvertently some small vessels are being cut which leads to oozing. The bleeding vessel is identified by the endoscopist and a firm pressure is applied by the distal hood to slow down the oozing till the coag-grasper can be inserted. The coag-grasper captures the vessel very precisely, as shown here, before coagulating it using a soft coagulation mode (50 W) to achieve adequate hemostasis. It is worth noting the importance of distal hood in hemostasis.
Scripted Voiceover Time (min:sec)
Voiceover text
00:00–00:14 (White light examination)
This clip demonstrates a long segment of Barrett’s with a large nodule at the bottom end. The nodule has a central two-c depressed area with some oozing and raises a concern of it being a submucosal (SM) invasive cancer.
00:15–00:40 (Acetic acid evaluation)
Acetic acid spray is now being performed mainly to identify any other neoplastic foci in the remaining Barrett’s. It is worth noting that the nodular area shows a very early loss of acetowhitening, which is suggestive of it being malignant. Acetic acid results in further oozing from the nodule and also highlights the irregular surface pattern confirming the suspicion of it being SM invasive nodule. However, the remaining Barrett’s looked healthy.
00:41–00:55 (Premarking of the lesion)
The margins of this nodular area are now being marked with the dual knife using a forced coagulation mode at 20 W and
Endoscopic Submucosal Dissection of Barrett’s Neoplasia
03.25–03.56 (Hook Knife and final dissection)
The knife is now being changed over to a hook knife, as that area is difficult to dissect with the dual knife. The hook knife is hooked into the submucosal fibers and pulled up and away from the muscle to avoid any perforation as shown here. Once the tricky area is dealt with, the endoscopist reverts back to a dual knife to perform the last bit of incision and achieve a complete single piece resection of the lesion.
03.57–04.15 (Assessment of the base & pinned specimen)
Once the lesion is resected then a very careful assessment of the ESD base is performed to look for any visible vessel or micro perforation which might require our attention. The specimen is then retrieved and pinned before it is sent to histopathology.
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References 1. Edwards, M. J.; Gable, D. R.; Lentsch, A. B.; Richardson, J. D. The Rationale for Esophagectomy as the Optimal Therapy for Barrett’s Esophagus with HighGrade Dysplasia. Ann. Surg. 1996, 223, 585–589. 2. Ferguson, M. K.; Naunheim, K. S. Resection for Barrett’s Mucosa with High-Grade Dysplasia: Implications for Prophylactic Photodynamic Therapy. J. Thorac. Cardiovasc. Surg. 1997, 114, 824–829. 3. Pellegrini, C. A.; Pohl, D. High-Grade Dysplasia in Barrett’s Esophagus: Surveillance or Operation? J. Gastrointest. Surg. 2000, 4, 131–134. 4. Konda, V. J. A.; Ross, A. S.; et al. Is the Risk of Concomitant Invasive Esophageal Cancer in High-Grade Dysplasia in Barrett’s Esophagus Overestimated? Clin. Gastroenterol. Hepatol. 2008, 159–164. 5. Gossner, L.; Behrens, A.; May, A.; et al. A Prospective Randomized Trial of Two Different Suck-and-Cut Mucosectomy Techniques in 100 Consecutive Resections in Patients with Early Cancer of the Esophagus. Gastrointest. Endosc. 2003, 58, 167–175. 6. Peters, F. P.; Brakenhoff, K. P.; et al. Histologic Evaluation of Resection Specimens Obtained at 293 Endoscopic Resections in Barrett’s Esophagus. Gastrointest. Endosc. 2008, 604–609. 7. Pech, O.; Gossner, L.; et al. Prospective Evaluation of the Macroscopic Types and Location of Early Barrett’s Neoplasia in 380 Lesions. Endoscopy 2007, 588–593.
