New Method
Use of modified multiband ligator facilitates circumferential EMR in Barrett's esophagus (with video)

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Background

Various techniques are available for EMR in the upper- and lower-GI tract. For early cancers of the esophagus, the “suck and cut” technique, which uses a transparent cap or variceal band ligator, is the most commonly practiced method. To facilitate multiple or circumferential EMR, a modified multiband variceal ligator (MBL) is introduced, which allows sequential banding and snare resection without the need to withdraw the endoscope.

Objective

To study the feasibility of modified MBL device in facilitating circumferential EMR of Barrett's esophagus (BE) that contains high-grade intraepithelial neoplasia (HGIN) and/or intramucosal cancer (IMC).

Design

To enable band delivery with a snare inserted in the therapeutic endoscope, the threading channel of the cranking device is enlarged from 2 to 3.2 mm. The 6-shooter MBL was used.

Patients

Ten consecutive patients (all men; median age, 62 years; range 43-82 years) with BE were treated. IMC and HGIN were found in 8 and 2 patients, respectively.

Interventions

EMR was performed with pure coagulating current when using a 1.5 × 2.5-cm mini hexagonal polypectomy snare. No submucosal saline solution injection was performed before resection.

Results

In 5 of 10 patients with circumferential BE of 2 to 9 cm in length (median, 4 cm), complete circumferential EMR was performed in 1 session by using 3 to 18 bands (median, 6). Four patients with 3- to 10-cm (median, 4 cm) long segment BE required 2 to 5 sessions (median, 3) with a total of 5 to 42 bands (median, 12). Another patient with multifocal HGIN and/or IMC in 24 of a total of 49 specimens was finally recommended for surgery because of technical difficulties caused by mural thickening after 4 sessions. No serious procedure-related complications were observed, except for 2 minor bleedings, which were controlled endoscopically. Seven patients developed strictures after circumferential EMR. All patients except 1 were successfully managed by weekly bougienage after a median of 5 sessions (range 3-11). Deep-wall tears developed in 1 patient during the fourth bougienage session, for which limited distal esophageal resection was performed with an uneventful outcome.

Conclusions

The novel technique of MBL-EMR described here facilitated and simplified circumferential removal of BE that contained HGIN and/or IMC. However, the method is associated with a very high stricture rate if circumferential EMR is performed in a single session. Complete removal of BE should be achieved by repeated partial EMR. Long-term follow-up is needed to observe for late recurrence and to determine the clinical impact of this method.

Section snippets

Patients and methods

The modification of the MBL (Wilson-Cook Medical Inc, Winston-Salem, NC) consists simply in widening the threading channel of the cranking device from 2 to 3.2 mm (Fig. 1). This allows for the insertion of a 7F catheter through the threading channel of the cranking device into the 3.7-mm working channel of the endoscope (GIF1T 140/160; Olympus Optical Co, Ltd, Tokyo, Japan). Band ligation can be performed with the polypectomy snare still within the working channel without any increased friction

Results

During a period of 6 months, a total of 10 consecutive patients were treated with the new MBL-EMR technique. All were men, with ages ranging from 43 to 82 years (median, 64 years). All patients had circumferential Barrett's segment with a length of 2 to 10 cm (median, 4 cm). In the initial biopsy before EMR, IMC was found in 8 cases and HGIN was found in two cases. No multifocal lesions were diagnosed.

In 5 of 10 patients, circumferential EMR was accomplished in one session by using 3 to 18

Discussion

In the last decade, various techniques of EMR have been introduced, mainly for early gastric cancer. The “strip biopsy,” initially performed as a biopsy in the stomach by Tada et al,23 was the first reported EMR method. This “lift and cut” technique with a double-channel endoscope was the most commonly used EMR method in Japan until 1998.24 The “suck and cut” technique with the transparent cap was popularized by Inoue et al.17 The en bloc resection method with an IT (insulation-tipped

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