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

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 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.

CGH and CD 44/MIB-1 immunohistochemistry are helpful to distinguish metastasized from nonmetastasized sporadic pheochromocytomas.

The natural course of pheochromocytomas (PCC) cannot be predicted for certain on the basis of primary histology, their malignant character can only be confirmed by the occurrence of metastases during follow-up. Based on the recently proposed PASS score for evaluation we examined 37 adrenal (36 sporadic and one familial) and six sporadic extra-adrenal paragangliomas (all designated as pheochromocytomas) with a 'malignant histology' to find additional predictive factors. Drawing upon the follow-up (18 months to 12 years, mean 5.8 years) metastasized (n=20) and nonmetastasized (n=23) courses could be distinguished. Metastasized PCC revealed significantly (P=0.03) more copy number changes on comparative genomic hybridization (CGH) (mean 8.3) than nonmetastasized tumors (mean: 4.3). The most frequent chromosomal alterations were losses on 1p (75.6%) and 3q (44%). Both were detected with identical frequency in metastasized and nonmetastasized PCC. A gain on 17q (P=0.025) was significantly predominant in malignant courses and suggests similarities in the genetic origin and progression of PCC and neuroblastomas. The proliferative activity (MIB-1 score) of metastasized PCC (n=20) was found to be significantly higher in metastasized tumors (mean 12.8% vs mean 3.5%). In contrast, the semiquantitatively scored membrane-bound staining of CD 44-S was stronger in tumors without metastases (mean 2.1 vs mean: 0.25) during the follow-up period (P<0.01). Although the results correspond to the established weight differences the tumor weight does not appear to be an independent prognostic factor. Our study suggests that CD 44-S and MIB-1 immunostaining as well as the CGH results might complement the PASS score in predicting a metastasized course of PCC. Regardless of tumor weight, tumors with a 'malignant histology' are highly prone to metastasize when more than 5% of MIB1-positive nuclei are present or CD44-S immunostaining is negative, or both. PCC with 10 or more copy number changes on CGH must be referred to as malignant tumors.

Circumferential EMR and complete removal of Barrett's epithelium: a new approach to management of Barrett's esophagus containing high-grade intraepithelial neoplasia and intramucosal carcinoma.

BACKGROUND: There is no study of circumferential EMR in patients with Barrett's esophagus containing early stage malignant lesions. This study investigated the effectiveness and safety of circumferential EMR by using a simple snare technique without cap. METHOD: Patients with Barrett's esophagus containing multifocal high-grade intraepithelial neoplasia or intramucosal cancer, and patients with endoscopically nonidentifiable early stage malignant mucosal changes incidentally detected in random biopsy specimens were included in the study. A 30 x 50-mm polypectomy snare made of monofilament 0.4-mm steel wire was used without any additional device or submucosal injection. RESULTS: Twelve patients (10 men, 2 women; median age 63.5 years, range 43-88 years) underwent circumferential EMR; 5 had multifocal lesions, and 7 had no visible lesions. Segments of Barrett's epithelium were circumferential (median length 5 cm) and completely removed. The median number of EMR sessions was 2.5. The median number of snare resections per EMR session was 5. The medial total area of mucosa in resected specimens per session was 3.8 cm(2). Two patients developed strictures that were successfully treated by bougienage. Minor bleeding occurred during 4 of 31 EMR sessions. During a median follow-up of 9 months, no recurrence of Barrett's esophagus or malignancy was observed. CONCLUSIONS: Circumferential EMR with a simple snare technique is feasible, safe, and effective for complete removal of Barrett's epithelium with early stage malignant changes.