Step 1

Surgical Anatomy

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  A comprehensive understanding of the anatomy of the esophagus before undertaking surgical procedures on the esophagus is critical.

  
  
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  Figure 30-1 illustrates the anatomic layers of the esophagus that must be considered when performing endoscopic mucosal resection (EMR) of high-grade Barrett esophagus.

  
  

  
  

  
  

  

  
  

Step 2

Preoperative Considerations

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  Ten percent of patients with symptomatic gastroesophageal reflux disease (GERD) will develop Barrett esophagus, typically after the sixth decade of life. More alarmingly, there is an associated 40-fold increase in risk for developing esophageal carcinoma in these patients. Although the pathophysiologic mechanism is still being investigated, it is thought to be exposure to bile and other reflux materials, not necessarily acid, that encourages the progression of dysplasia to cancer. Many patients with intestinal metaplasia of the distal esophagus are asymptomatic. Other patients have the typical symptoms of heartburn, regurgitation, acid or bitter taste in the mouth, excessive belching, and indigestion that are associated with GERD.

  
  
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  The diagnosis of Barrett esophagus is made on endoscopic visualization of any segment of columnar mucosa within the esophagus that on pathology identifies intestinal metaplasia.

  
  
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  Limited data and an incomplete understanding of the mechanisms leading to Barrett esophagus have made treatment of this disease controversial. Current treatment options include surveillance endoscopy, antireflux surgery, ablative therapy, EMR, and esophageal resection. EMR serves as both a diagnostic and possibly curative treatment option that also preserves the esophagus. Further, it is a possible treatment option for patients with high-grade Barrett esophagus who are not acceptable candidates for esophagectomy.

  
  
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  Several techniques have been developed for EMR; the most commonly used and technically feasible methods are the EMR cap and EMR band ligation techniques that are discussed here.

  
  
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  The anesthetic approach is dictated by the co-morbidities of the patient, length of the procedure, as well as patient tolerance. The anesthesia for this procedure can range from conscious sedation to a general anesthetic.

  
  
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  The patient is placed in the left lateral decubitus position and prepped in typical endoscopic fashion.

  
  
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  For EMR in the esophagus, a large, soft cap (D-206-01-06, Olympus America, Center Valley, PA) is generally used for the first resection intending to acquire a large sample. The conventional hard-type transparent cap is preferably used just in case it is needed for additional resections or for resecting a small lesion. The outer diameter of the large, soft cap is 18 mm. There is an inner circular rim at the tip of the large, soft cap for the prelooping process. The scope used is the normal observation endoscope (e.g., –240 and so on).

Step 3

Operative Steps