Endoscopy 2014; 46(S 01): E149-E150
DOI: 10.1055/s-0034-1364946
Cases and Techniques Library (CTL)
© Georg Thieme Verlag KG Stuttgart · New York

Are endoscopic mucosal resection and endoscopic submucosal dissection risky for patients with cirrhosis?

Fatih Aslan
1   Department of Gastroenterology, Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey
,
Zehra Akpinar
1   Department of Gastroenterology, Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey
,
Ali Riza Seren
2   Department of Anesthesiology and Reanimation, Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey
,
Emrah Alper
1   Department of Gastroenterology, Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey
,
Cem Cekic
1   Department of Gastroenterology, Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey
,
Nese Ekinci
3   Department of Pathology, Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey
,
Sezgin Vatansever
1   Department of Gastroenterology, Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey
,
Belkis Unsal
1   Department of Gastroenterology, Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey
› Author Affiliations
Further Information

Corresponding author

Fatih Aslan, MD
Yali Mahallesi
I. Tarik Sari Caddesi
Aktas Evleri-1, B Blok
No: 16, Daire: 5
35310, Guzelbahce
Izmir
Turkey   

Publication History

Publication Date:
22 April 2014 (online)

 

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) have become a standard treatment in selected cases of early gastric cancer [1] [2]. The risk of complications may increase in patients with cirrhosis, due both to severe clotting impairment and to decreased platelet counts [3]. We present our experience in three patients with cirrhosis.

A 68-year-old woman with cryptogenic cirrhosis and esophageal varices, who had normal laboratory parameters and platelet count, was diagnosed with a high-grade gastric adenoma. ESD was decided on. Lesion margins were marked. A solution of mixed saline, adrenaline, and indigo-carmine was used for submucosal injection. Circumferential incision and submucosal dissection were carried out using a HookKnife and an ITknife2 (Olympus, Tokyo, Japan). A Coagrasper (Olympus) was used for preventive hemostasis. The lesion was removed en bloc in 61 minutes ([Figs. 1, 2]). Pathological examination revealed a high-grade gastric adenoma. A prophylactic antibiotic was administered. Endoscopy at 6-month follow-up showed no recurrence.

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Fig. 1 a Endoscopic appearance (i-scan) of gastric lesion. b Marking the lesion with the HookKnife. c Submucosal injection.
Zoom Image
Fig. 2 a View of submucosal tissue through endoscope hood. b Mucosal defect after endoscopic submucosal dissection. c Resected specimen.

A 69-year-old man was diagnosed with decompensated cryptogenic cirrhosis (esophageal varices and ascites). Serum bilirubin and albumin levels were 1.9 mg/dL and 2.2 g/dL respectively. Platelet count was 59 × 103/μL and INR was 1.42. Endoscopic evaluation showed a sessile polyp (width 10 mm) in the gastric body. The polyp was elevated by administering a mixture of saline and adrenaline, and was then removed en bloc using a polypectomy snare. Pathological examination revealed a grade 1 neuroendocrine tumor. Prophylactic antibiotic therapy was administered.

A 55-year-old woman was diagnosed as having hepatitis C virus-related cirrhosis. Blood chemistry was normal except for the platelet count (91 × 103/μL). Five sessile polyps (the largest 15 mm, the others 6 – 8 mm) were seen in the gastric body during endoscopy. The largest polyp was elevated as described above and removed en bloc using a polypectomy snare. EMR with a ligation device was planned for the remaining polyps. The lesions were elevated, band ligation was applied, and EMR was performed below the band with a polypectomy snare ([Figs. 3, 4]). Pathological examination revealed grade 1 neuroendocrine tumor for all lesions. A prophylactic antibiotic was administered.

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Fig. 3 a Endoscopic appearance of gastric lesion. b, c Application of endoscopic band ligation to lesions.
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Fig. 4 a View after endoscopic resection with snare. b Mucosal defects after endoscopic mucosal resection. c Resected specimens

Patients with cirrhosis are at increased risk of developing gastric lesions [4]. Surgical treatment in these patients is associated with high mortality [5]. The risk of bleeding during ESD in patients with cirrhosis is reported to be 4 % – 33 %. INR below 1.5 and a platelet count above 50 × 103/μL are likely to be safe thresholds for endoscopic resection [3] [6] [7] [8]. There is a risk of sepsis in cirrhotic patients due to impairment of defensive mechanisms [9]. Prophylactic antibiotics can reduce the risk of bacteremia and sepsis.

Endoscopy_UCTN_Code_TTT_1AO_2AG


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Competing interests: None

  • References

  • 1 Yamamoto H, Kita H. Endoscopic therapy of early gastric cancer. Best Pract Res Clin Gastroenterol 2005; 19: 909-926
  • 2 Soetikno R, Kaltenbach T, Yeh R et al. Endoscopic mucosal resection for early cancers of the upper gastrointestinal tract. J Clin Oncol 2005; 23: 4490-4498
  • 3 Ferro D, Angelico F, Caldwell SH et al. Bleeding and thrombosis in cirrhotic patients: what really matters?. Dig Liver Dis 2012; 44: 275-279
  • 4 Zullo A, Romiti A, Tomao S et al. Gastric cancer prevalence in patients with liver cirrhosis. Eur J Cancer Prev 2003; 12: 179-182
  • 5 Douard R, Lentschener C, Ozier Y et al. Operative risks of digestive surgery in cirrhotic patients. Gastroenterol Clin Biol 2009; 33: 555-564
  • 6 Kwon YL, Kim ES, Lee KI et al. Endoscopic treatments of gastric mucosal lesions are not riskier in patients with chronic renal failure or liver cirrhosis. Surg Endosc 2011; 25: 1994-1999
  • 7 Repici A, Pagano N, Hassan C et al. Endoscopic submucosal dissection of gastric neoplastic lesions in patients with liver cirrhosis: a systematic review. J Gastrointestin Liver Dis 2012; 21: 303-307
  • 8 Zullo A, Hassan C, Bruzzese V. Comment to “Bleeding and thrombosis in cirrhotic patients: what really matters?”. Dig Liver Dis 2012; 44: 1049
  • 9 Garcia-Tsao G. Current management of the complications of cirrhosis and portal hypertension: variceal hemorrhage, ascites, and spontaneous bacterial peritonitis. Gastroenterology 2001; 120: 726-748

Corresponding author

Fatih Aslan, MD
Yali Mahallesi
I. Tarik Sari Caddesi
Aktas Evleri-1, B Blok
No: 16, Daire: 5
35310, Guzelbahce
Izmir
Turkey   

  • References

  • 1 Yamamoto H, Kita H. Endoscopic therapy of early gastric cancer. Best Pract Res Clin Gastroenterol 2005; 19: 909-926
  • 2 Soetikno R, Kaltenbach T, Yeh R et al. Endoscopic mucosal resection for early cancers of the upper gastrointestinal tract. J Clin Oncol 2005; 23: 4490-4498
  • 3 Ferro D, Angelico F, Caldwell SH et al. Bleeding and thrombosis in cirrhotic patients: what really matters?. Dig Liver Dis 2012; 44: 275-279
  • 4 Zullo A, Romiti A, Tomao S et al. Gastric cancer prevalence in patients with liver cirrhosis. Eur J Cancer Prev 2003; 12: 179-182
  • 5 Douard R, Lentschener C, Ozier Y et al. Operative risks of digestive surgery in cirrhotic patients. Gastroenterol Clin Biol 2009; 33: 555-564
  • 6 Kwon YL, Kim ES, Lee KI et al. Endoscopic treatments of gastric mucosal lesions are not riskier in patients with chronic renal failure or liver cirrhosis. Surg Endosc 2011; 25: 1994-1999
  • 7 Repici A, Pagano N, Hassan C et al. Endoscopic submucosal dissection of gastric neoplastic lesions in patients with liver cirrhosis: a systematic review. J Gastrointestin Liver Dis 2012; 21: 303-307
  • 8 Zullo A, Hassan C, Bruzzese V. Comment to “Bleeding and thrombosis in cirrhotic patients: what really matters?”. Dig Liver Dis 2012; 44: 1049
  • 9 Garcia-Tsao G. Current management of the complications of cirrhosis and portal hypertension: variceal hemorrhage, ascites, and spontaneous bacterial peritonitis. Gastroenterology 2001; 120: 726-748

Zoom Image
Fig. 1 a Endoscopic appearance (i-scan) of gastric lesion. b Marking the lesion with the HookKnife. c Submucosal injection.
Zoom Image
Fig. 2 a View of submucosal tissue through endoscope hood. b Mucosal defect after endoscopic submucosal dissection. c Resected specimen.
Zoom Image
Fig. 3 a Endoscopic appearance of gastric lesion. b, c Application of endoscopic band ligation to lesions.
Zoom Image
Fig. 4 a View after endoscopic resection with snare. b Mucosal defects after endoscopic mucosal resection. c Resected specimens