Gastroscopy with Endoscopic Mucosal Resection (EMR)

Before your appointment

• All medications should be taken as normal with a little water.
• If you take Warfarin or Clopidogrel or other blood thinning medication please contact the Endoscopy Nurses when you receive this information on 01223 216515. You may need to stop your medication prior to your procedure. if you take Aspirin only please continue.
• If you have implanted cardiac device such as a Pacemaker or Implanted Cardioverter Defibrillator please contact the endoscopy Unit on 01223 216515.
• If you have any questions about the procedure or find that you cannot keep this appointment, please contact the endoscopy office between 9:00 and 17:00 Monday to Friday on 01223 257080.

On the day

• Have nothing to eat for six hours and nothing to drink for four hours before your appointment.
• Please ensure you have arranged an escort home. We cannot sedate you if you do not provide details of your escort.

At the hospital

• Please come to the endoscopy department on level 3 of the Addenbrooke’s Treatment Centre (ATC).
• Use the ‘Car Park 2’. The car park is busy early in the morning; please allow yourself enough time to arrive in time for your appointment. Take your parking ticket to the endoscopy reception desk to have your ticket stamped; this will enable you to have discounted parking.
• Please note you need to arrive 30 minutes prior to your appointment time for your pre procedure check. The length of time you will be here will vary enormously but may be anything from two to four hours or more. Please ask your admitting nurse for further information during your admission check.

What is a gastroscopy and EMR?

Your doctor has requested this procedure to help investigate and manage your medical condition. This is a specialist procedure and will be performed by a consultant who has been trained in endoscopic mucosal resection and is experienced in specialist endoscopy techniques.

Gastroscopy is an examination of the upper gut, which is the oesophagus (gullet), the stomach and duodenum (part of the small intestine joining the stomach). The procedure involves passing a narrow flexible instrument through the mouth, into the gullet (oesophagus) and then into the stomach and duodenum to examine the lining.

About endoscopic mucosal resection (EMR)

Endoscopic mucosal resection is the name given to a procedure where specialised endoscopic devices are used to remove abnormal areas in the lining of the oesophagus (gullet) or the stomach.

Is endoscopic mucosal resection (EMR) widely used?

Endoscopic mucosal resection has been used for many years in Japan and the Far East for the treatment of early stomach cancer. The techniques are now increasingly widely used in Europe and the UK.

What is the aim of endoscopic mucosal resection (EMR)?

EMR allows us to remove larger areas of the gullet or stomach lining than standard endoscopic biopsy samples. This allows us to obtain larger pieces of tissue for analysis under the microscope and help us plan further treatment as necessary. EMR can also be a therapeutic intervention when the whole of the abnormal area is removed with the endoscopy.

Who is suitable for endoscopic mucosal resection (EMR)?

All patients who have conditions potentially suitable for EMR are discussed in a multidisciplinary meeting. At this meeting, specialists in a number of different fields discuss the best treatment options for each individual patient.

Patients with small polyps in the gullet and stomach or abnormal areas detected using other methods are potentially suitable for EMR.

Getting ready for the procedure

Wear loose fitting washable clothing and leave valuables at home.

On arrival to the department

Please register your arrival with the receptionist, they will ask for your pre-procedure questionnaire. Some patients may arrive after you but be seen quicker; we have seven procedure rooms all undertaking different procedures therefore patients are not seen in arrival order.

Before your procedure you will meet one of the nurses who will ask you some health questions and explain the procedure to you.

Once this is completed, you will be escorted to a single sex changing area. You are able to wear your own clothes for this procedure. Your escort cannot wait with you from this point and can leave the department until you are ready to go home.

You can change your mind about having the procedure at any time.

Sedatives

Endoscopic mucosal resection is performed under sedation. You can also be offered anaesthetic throat spray so that you are as comfortable as possible during the procedure.

The sedation will be administered via a plastic tube called a cannula which is inserted into a vein, and will make you feel relaxed and sleepy but not unconscious (this is not a general anaesthetic). This option means you may not be aware of the procedure.

As you will required sedation:

• You will need to stay whilst you recover which may take up to an hour or more.
• You will need to be escorted home; your procedure will be cancelled if you do not have an escort.
• The injection will continue to have a mild sedative effect for up to 24 hours and may leave you unsteady on your feet for a while.

What happens during the procedure?

You will be collected from the changing room by the endoscopist and taken to a private bay to complete your consent form, when this has been completed they will escort you to the procedure room. The team in the procedure room will introduce themselves and ask you some questions; this is to confirm you are ready and prepared to continue with the procedure.

In the procedure room, we will ask you to remove false teeth, glasses and hearing aids in the left ear. We will make you comfortable on a couch lying on your left side. We will also need to place a sticky pad on your right hip, which is part of the cauterizing device.

An intravenous injection is given into a vein to make you feel relaxed and sleepy, but not unconscious (this is not a general anaesthetic). This will be used to give you two sedative medications during the procedure. We will put a plastic guard into your mouth so that you do not bite and damage our instrument. We will also put a plastic ‘peg’ on your finger to monitor your pulse and oxygen levels. For your comfort and reassurance, a trained nurse will stay with you throughout.

When you are sleepy, the endoscope is passed down your gullet to look carefully at the area to be treated in the gullet or in the stomach. Once the area has been assessed and we have confirmed it is suitable to carry out EMR, the area to be treated will be marked using a cautery device (also called a ‘snare’) passed down through the endoscope.

The endoscope will then be removed and the device for performing the EMR will be attached to it. The endoscope is then passed back down your gullet and the EMR performed. When this is finished, it is necessary to retrieve the tissue pieces we have removed from the lining. In order to do this, we first take out the endoscope and remove the EMR device. The endoscope is then passed down the gullet again and a special net passed through the endoscope that allows us to collect and remove the tissue pieces.

On average, the procedure will take about 20 to 30 minutes. We will ensure you receive adequate sedation for the whole time the procedure takes. Minimal restraint may be appropriate during the procedure. However if you make it clear that you are too uncomfortable the procedure will be stopped.

Serious or frequently occurring risks

• Endoscopic mucosal resection is a safe procedure and serious complications are very rare.
• The major risks are perforation (tear through the wall of the gullet or stomach) and bleeding and both are potentially serious. We estimate that these complications may occur in 2 to 3% of people who undergo EMR.
• Other rare complications include aspiration pneumonia (inflammation of the lungs caused by inhaling or choking on vomit) and an adverse reaction to the intravenous sedative and analgesic drugs.
• If we are concerned a complication has occurred during the procedure, you may be kept in hospital for observation.
• When you go home, you should contact us if you experience any of the following:
  • Chest pain
  • Great difficulty swallowing
  • Shortness of breath
  • Fever
  • Abdominal pain
  • Bleeding

After the procedure

If you had sedation, we will take you to a recovery area while the sedation wears off. When you are sufficiently awake, we will give you a drink. You can then go home; this may be up to an hour following the procedure.

We advise you not to drive, operate machinery, return to work, drink alcohol or sign legally binding documents for a 24-hour period after the procedure. We also advise you to have a responsible adult to stay with you for the next 12 hours.

• Eating and drinking: After the procedure, you should drink liquids only for the following day. These liquids (this does include soup) should not be too hot or too cold – around room temperature is the best.
• After 24 hours, we recommend you begin taking soft, sloppy foods and continue with this for the next five days.
• You should remain on your acid reducing medication continuously and you can be advised to double the dose for the week following the procedure and introduce other medication to improve the healing of your stomach or gullet lining
• You can also take simple ‘over the counter’ indigestion remedies.
• After endoscopic mucosal resection, you may notice some after effects for as long as 10 to 14 days.
• These effects most commonly consist of mild chest discomfort (like heartburn) and mild discomfort when you eat food.
• Paracetamol should be sufficient to relieve this discomfort.
• You should not take Aspirin or other non-steroidal painkillers (such as Ibuprofen or Diclofenac).

You may feel a little bloated and have some wind-like pains because of the air in your gut; these usually settle down quickly.

We will always do our best to respect your privacy and dignity, e.g. with the use of curtains. If you have any concerns, please speak to the department sister or charge nurse.

When will I know the result?

If you did not have sedation the endoscopist or endoscopy nurse will give you information during and immediately after the procedure. If you had sedation, we will tell you about the procedure in the recovery area when you are awake. If you would like more privacy, we will take you to a private room.

The sedation can affect your ability to remember any discussion. If you would like someone with you when you talk to the endoscopist or endoscopy nurse please inform the nurse looking after you who will arrange for you to be seen in a private room with your escort when they arrive.

You will be informed of the results of the analysis performed on the tissue we remove at an outpatient appointment or with a telephonic consultation depending on your preference. At this time, we will also discuss with you our recommendations about further treatment you may require.

Information and support

You might be given some additional patient information before or after the procedure, for example: leaflets that explain what to do after the procedure and what problems to look out for. If you have any questions or anxieties, please feel free to ask a member of staff.

After discharge

We will provide you with an information sheet on discharge which will detail who to contact if you require any assistance after the procedure.

What are the alternatives to endoscopic mucosal resection (EMR)?

The current alternatives to EMR techniques include for small areas laser beams (APC) to destroy (ablate) the lining of the gullet or stomach and surgery.