Techniques of Esophageal Preservation for High-Grade Barrett Esophagus





Surgical Anatomy





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



  • 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.




    Figure 30-1






Preoperative Considerations





  • 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.



  • 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.



  • 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.



  • 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.



  • 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.



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



  • 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).






Operative Steps



Isolation of Mucosal Layers





  • This initial step in isolating the lesion to be excised is common to all techniques of EMR. Using a standard upper endoscope, the lesion is visualized. Depending on physician preference, the margins of the lesion may then be marked using electrocautery. Submucosal injection allows elevation of the mucosa from the muscular layers to avoid perforation of the esophagus. An injection needle is passed into the endoscope to inject, most commonly, a diluted epinephrine in saline solution into the submucosa. This injection has a duration of approximately 5 minutes and may require repeating to avoid muscular damage. Alternative solutions for submucosal injection are discussed in Table 30-1 .



    Table 30-1

    Alternative Solutions for Submucosal Injection






















































    SOLUTION CUSHION DURATION ADVANTAGES DISADVANTAGES
    Normal saline solution (0.9%) w/epinephrine + Easy to inject, cheap, readily available Quickly dissipates
    Hypertonic solution of sodium chloride (3.0%) ++ Easy to inject, cheap, readily available Tissue damage, local inflammation at injection sites
    Hyaluronic acid +++ Longest-lasting cushion Expensive, not readily available, storage requirements, might stimulate residual tumor cell growth
    Hydroxypropyl methylcellulose +++ Long-lasting cushion, relatively inexpensive Tissue damage, local inflammation at injection sites
    Glycerol ++ Cheap, readily available
    Dextrose ++ Cheap, readily available Tissue damage, local inflammation at injection sites
    Albumin ++ Easy to inject, readily available Expensive
    Fibrinogen +++ Easy to inject, long-lasting cushion Expensive, not readily available
    Autologous blood +++ Clotting in syringe if injection delayed Religious beliefs may preclude, limited human data

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Mar 13, 2019 | Posted by in CARDIOLOGY | Comments Off on Techniques of Esophageal Preservation for High-Grade Barrett Esophagus
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