Endoscopic mucosal resection: tips and tricks for gastrointestinal trainees

Abstract

Endoscopic mucosal resection (EMR) is a minimally invasive, specialized endoscopic technique that is useful in resecting superficial gastrointestinal lesions that are unable to be removed by standard polypectomy. This is typically accomplished using a submucosal injection that lifts the lesion away from the muscularis propria to allow for safe resection of the polyp, either via piecemeal or en bloc resection. Over the years, several techniques exist to perform EMR including conventional EMR or hot EMR, cold EMR and underwater EMR. Despite its established advantages and safety over conventional techniques such as surgery, the adoption of endoscopic resection (and thus the education and training of gastroenterology trainees) is lagging. The goal of this article is to offer a comprehensive review of the basic principles of colonic EMR. We review the concepts of optical diagnosis including the various polyp classification systems available to determine the polyp morphology and histology. We also discuss the technical aspects of performing colonic EMR. We also outline the common adverse events associated with EMR including bleeding, perforation, postpolypectomy syndrome, and residual or recurrent polyps, and discuss preventative measures that can be taken to mitigate adverse events. Lastly, we offer practical tips for trainees who want to undertake EMR in their clinical practice.

Endoscopic techniques for management of large colorectal polyps, strictures and leaks

“…Premixed commercial injecting agents are also available. The solution can also be diluted with epinephrine (in concentrations ranging from 1:100,000 or 1:1,000,000) to decrease intra-procedural bleeding, however, this has been associated with an increased risk of delayed bleeding [ 11 , 12 ].…”

“…It was originally developed in Japan in the 1990s for gastric malignancies, and its applications have since expanded to other parts of the GI tract [ 26 ]. When evaluating polyps for high-risk criteria, it is recommended to use chromoendoscopy, narrow-band imaging, blue light imaging or EUS [ 11 ]. If there is concern based on careful evaluation that there may be submucosal invasion (depressed edges, ulceration, and irregular pit pattern), one can biopsy instead of attempting resection.…”