En bloc esophageal mucosectomy for concentric circumferential mucosal resection (with video)

BackgroundWith conventional EMR, specimens are fragmented, metaplasia may be left behind, and invasive lesions could be missed because of incomplete sampling. Concentric subtotal esophageal mucosectomy would address these limitations.ObjectiveTo examine en bloc esophageal mucosectomy (EEM).DesignA prospective case series.SettingAn academic hospital.SubjectsNine swine.InterventionsConventional EMR was performed in the proximal esophagus. The submucosal space was entered, and the distal two thirds of the esophageal mucosa was freed with blunt dissection. A snare was threaded over the column of mucosa to the gastroesophageal junction. The column was resected, and the mucosa was retrieved.Main Outcome and MeasurementsClinical examination, follow-up endoscopy, necropsy, and gross and histopathologic examination.ResultsEEM permitted subtotal esophageal mucosectomy in 9 of 9 swine (tissue specimens removed ranged 9-15 cm in length). The mean procedure duration was 110 minutes. In the survival series, 4 of 4 swine thrived after surgery, for 9 to 13 days. At 9 days, there was no evidence of a perforation, stricture, or leak. At 13 days, 2 swine had a mild proximal stricture, which was easily traversed with a 9.8-mm gastroscope. On necropsy, the mediastinal and thoracic cavities were unremarkable in 3 of 4 swine. One swine was found to have a contained abscess containing cellulose, presumably secondary to ingestion of wood-chip bedding material postoperatively. Reepithelialization was present on histologic examination.LimitationsAn animal study.ConclusionsEEM is feasible and enabled concentric subtotal esophageal mucosal resection. The technique could completely and circumferentially excise intramucosal lesions. Longer follow-up and larger studies are needed to evaluate infection, stricture, and safety.