Endoscopic Mucosal Resection
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About This Procedure
Endoscopic mucosal resection (EMR) is a specialized endoscopic technique used by gastroenterologists at the Massachusetts General Hospital Digestive Healthcare Center to diagnose and remove large areas of early cancers arising in the gastrointestinal tract, including the esophagus, stomach, small intestine and colon.
EMR has become an important and safe alternative to surgery for the treatment of early cancer arising from conditions including Barrett’s esophagus.
EMR gives specialists access to areas of diseased tissue about the size of a penny—four or five times larger than a typical biopsy. EMR may be recommended for patients with suspected high-grade dysplasia, or early cancer, because it allows the gastroenterologist to not only accurately diagnose the stage of growth but also to provide complete therapy by removing the diseased tissue.
How Is EMR Performed?
EMR is performed on an outpatient basis by a gastroenterologist. Under the care of an anesthesiologist, the patient will receive either deep sedation or general anesthesia. During EMR a thin, flexible tube (endoscope) is inserted through the mouth and into the esophagus, the pathway that connects the mouth to the stomach. The tip of the flexible endoscope has a lens and a light source, which allow images to be sent to a monitor for close inspection of the lining of the upper gastrointestinal tract.
Using an instrument attached to the tip of the endoscope, the gastroenterologist can suction small nodules or growths and trap them in a small, rubber band. This tissue is then removed using an instrument that cuts the tissue. This technique can be repeated in nearby areas, as necessary, to ensure all abnormal tissue is removed. The tissue that has been removed is then carefully evaluated by a pathologist.
Patients with high-grade dysplasia or intramucosal carcinoma (the earliest stage of esophageal cancer) often undergo an endoscopic ultrasound exam before undergoing the resection to ensure there is no deeper tissue involvement.
The procedure typically takes 25 to 35 minutes.
What Preparation Is Required Before EMR?
The patient will be asked not to eat or drink anything after midnight the night before the procedure. If the patient takes daily medication in the form of a pill, he/she may take it with sips of water the morning of the EMR.
Patients must be off blood thinner medications, such as coumadin, aspirin and plavix to safely perform EMR.
What Is the Recovery Time?
Patients are discharged from the Mass General endoscopy unit with prescriptions for oral pain medications and an oral numbing solution they may use for five to seven days.
A modified diet is recommended for the first three days after the procedure to allow time for healing. Patients may return to work the day after the procedure.
EMR for Barrett’s Esophagus
Gastroenterologists in the Mass General Barrett's Esophagus Treatment Center have been performing EMR since 2003 and have successfully treated hundreds of patients.
Patients who are treated for Barrett’s esophagus with EMR return for a follow-up endoscopy in two to three months to ensure they are healing properly. In most cases, additional treatment in the form of radiofrequency ablation (RFA) or cryotherapy is performed at this time to eradicate the remaining Barrett’s tissue.
All patients with Barrett’s esophagus will also be treated with high dose antacids (typically in the proton pump inhibitor family) indefinitely. A low-acid environment helps the body replace the removed tissue with normal tissue (squamous mucosa). Patients will remain in a surveillance program indefinitely to ensure that the Barrett’s mucosa, or diseased tissue, does not recur.
For a subset of patients who undergo EMR for Barrett's esophagus, esophagectomy (surgery to remove the esophagus) may be recommended if the pathology results point to deeper tissue involvement.
How Safe Is the Procedure?
EMR is a safe and well-tolerated procedure. However, about 20% of patients may have chest pain following the procedure.
About 5% of patients may develop narrowing of the esophagus (known as a stricture) as a result of EMR and may require one or more procedures to stretch the esophagus (known as dilations) to treat this.
Major complications are uncommon (occur in less than 1% of patients), but may include bleeding or perforation of the esophagus.
EMR is performed at Mass General in Boston and at the Mass General/North Shore Center for Outpatient Care in Danvers, MA.