Use of modified multiband ligator facilitates circumferential EMR in Barrett's esophagus

Background Various techniques are available for EMR in the upper- and the lower-GI tract. For early cancers of the esophagus, the “suck and cut” technique that 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. 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 3.3 mm. The 6-shooter MBL was used. Ten consecutive patients (all men; median age, 62 years; range 43-82 years) with Barrett's esophagus (BE) were treated. Intramucosal cancer (IMC) and high-grade intraepithelial neoplasia (HGIN) were found in 8 and two patients, respectively. EMR was performed with pure coagulating current when using a 1.5 × 2.5-cm mini hexagonal polypectomy snare. No submucosal saline solution injection was performed before resection. Observations In 5 of 10 patients with circumferential BE of 2 to 9 cm in length (median, 4 cm), complete circumferential EMR was performed in one 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 two minor bleedings, which were controlled endoscopically. Seven patients developed strictures after circumferential EMR. All patients except one were successfully managed by weekly bougienage after a median of 5 sessions (range 3-11). Deep-wall tears developed in one 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 one 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 t