title: Use of modified multiband ligator facilitates circumferential EMR in Barrett's esophagus (with video).
abstract: 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).
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  EMR was performed with pure coagulating current when using a 1.5 x 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.
authors.affiliation: Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
authors.forename: Nib
authors.initials: N
authors.lastname: Soehendra
authors.forename: Stefan
authors.initials: S
authors.lastname: Seewald
authors.forename: Stefan
authors.initials: S
authors.lastname: Groth
authors.forename: Salem
authors.initials: S
authors.lastname: Omar
authors.forename: Uwe
authors.initials: U
authors.lastname: Seitz
authors.forename: Yan
authors.initials: Y
authors.lastname: Zhong
authors.forename: Andreas
authors.initials: A
authors.lastname: de Weerth
authors.forename: Frank
authors.initials: F
authors.lastname: Thonke
authors.forename: Soeren
authors.initials: S
authors.lastname: Schroeder
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001471:Barrett Esophagus / Q000601:surgery*; D004867:Equipment Design; D004938:Esophageal Neoplasms / Q000601:surgery; D004940:Esophageal Stenosis / Q000209:etiology; D004945:Esophagoscopy / Q000009:adverse effects / Q000379:methods; D005240:Feasibility Studies; D006801:Humans; D008026:Ligation / Q000295:instrumentation; D008297:Male; D008875:Middle Aged; D009092:Mucous Membrane / Q000601:surgery