A 72 y/o male with h/o CAD, NIDDM & mild GERD for A 72 y/o male with h/o CAD, NIDDM & mild GERD for 6-7 yrs on occasional PPI who started to have 6-7 yrs on occasional PPI who started to have intermittent solid food dysphagia for few weeks. His intermittent solid food dysphagia for few weeks. His EGD showed a 1.5 cm nodule at the EGJ & biopsy EGD showed a 1.5 cm nodule at the EGJ & biopsy revealed adenocarcinoma.revealed adenocarcinoma.

• PMH/PSHPMH/PSH: NIDDM x 25 yrs; CAD & CABG in : NIDDM x 25 yrs; CAD & CABG in ’02/stents ’02/stents in ’03. in ’03.• MEDMED: Plavix, Avandia, Metformin, & Nexium. : Plavix, Avandia, Metformin, & Nexium. • ALLALL: Niacin: Niacin• SHSH: Tobacco 1p/d x 20 yrs & quit 30 yrs ago; No : Tobacco 1p/d x 20 yrs & quit 30 yrs ago; No ETOH ETOH or IVDA. or IVDA.• FHFH: Mother had larynx ca & both sisters had : Mother had larynx ca & both sisters had lung ca.lung ca.• ROSROS: Noncontributory.: Noncontributory.• PEPE: Essentially unremarkable.: Essentially unremarkable.• LABLAB: CBC-diff, SMA-6, PT & INR were WNL.: CBC-diff, SMA-6, PT & INR were WNL.

Abd/pelvic CTAbd/pelvic CT Upper EUS Upper EUS

ENDOSCOPIC MUCOSAL RESECTIONENDOSCOPIC MUCOSAL RESECTION

ENDOSCOPIC MUCOSAL RESECTIONENDOSCOPIC MUCOSAL RESECTION

A 77 y/o female with a COPD who has been seen A 77 y/o female with a COPD who has been seen by TMH/BCM liver team with an obstructive by TMH/BCM liver team with an obstructive jaundice in Jan ’00 and referred for a surgical jaundice in Jan ’00 and referred for a surgical consult. Denied fever, wt loss, pruritis, GIB.consult. Denied fever, wt loss, pruritis, GIB.

• MEDMED: Cipro, Actigall: Cipro, Actigall• PMHPMH: COPD for 10-12 yrs.: COPD for 10-12 yrs.• SHSH: Tobacco 1 p/d for 50yrs, no ETOH or IVDA: Tobacco 1 p/d for 50yrs, no ETOH or IVDA• FH & ROSFH & ROS: Noncontributory: Noncontributory• PEPE: VSS, icteric & chest increased AP : VSS, icteric & chest increased AP

diamater, diamater, prolonged expirium, prolonged expirium, hepatomegaly.hepatomegaly.

• LABLAB: WBC 11, H/H 14.6/41, Pl 171& lyts, FBS,: WBC 11, H/H 14.6/41, Pl 171& lyts, FBS, PT, INR were all WNL. Alk.phos. 378, bil.PT, INR were all WNL. Alk.phos. 378, bil. 6.8 & ALT/AST 147/128.6.8 & ALT/AST 147/128. Abd US& abd/pelvic CT Abd US& abd/pelvic CT

ERCP ERCP

ENDOSCOPIC PAPILLECTOMY in a 77 y/o female with ENDOSCOPIC PAPILLECTOMY in a 77 y/o female with adenomaadenoma

11/9/2000 5/12/2005

ENDOSCOPIC PAPILLECTOMY in a 68 y/o female with ENDOSCOPIC PAPILLECTOMY in a 68 y/o female with adenomaadenoma

EMR in a 64 y/o male with cecal villousadenomaEMR in a 64 y/o male with cecal villousadenoma

EMR in a 83 y/o female with rectal villousadenomaEMR in a 83 y/o female with rectal villousadenoma

EMR in a 64 y/o male with 7 cm rectal EMR in a 64 y/o male with 7 cm rectal villousadenomavillousadenoma

9/15/2000

11/1/2001

4/21/2001

6/17/2005

ENDOSCOPICENDOSCOPIC MUCOSAL RESECTION MUCOSAL RESECTION (EMR)(EMR)• EMREMR first proliferated in Japan. first proliferated in Japan.

• The The EMREMR combines the therapeutic combines the therapeutic power ofpower of endoscopic procedure with the diagnostic power endoscopic procedure with the diagnostic power of pathology exam of resected neoplastic lesion of pathology exam of resected neoplastic lesion in selected cases.in selected cases.

• Saline assisted or cap-assisted Saline assisted or cap-assisted EMR EMR have been have been safe and effective for GI mucosal cancers.safe and effective for GI mucosal cancers.

• EMREMR using electrocautery knives has shown safe using electrocautery knives has shown safe &&

effective for submucosal lesions in expert hands.effective for submucosal lesions in expert hands.

Gastrointest Endosc 59: 171 & 273, 2004.Gastrointest Endosc 59: 171 & 273, 2004.

Endoscopy 38: 521, 2005Endoscopy 38: 521, 2005

ENDOSCOPIC PAPILLECTOMY (EP)ENDOSCOPIC PAPILLECTOMY (EP)

• Ampullary adenomas can be removed by Ampullary adenomas can be removed by combination of combination of EPEP & APC in selected cases after & APC in selected cases after prophylactic pancreatic and sometimes biliary prophylactic pancreatic and sometimes biliary stenting.stenting.

• These lesions can progress through an adenoma-These lesions can progress through an adenoma-carcinoma sequences.carcinoma sequences.

• Complications of Complications of EPEP occurred in about 20% such occurred in about 20% such as bleeding, perforation & pancreatitis.as bleeding, perforation & pancreatitis.

• Depending upon the size & path of the lesion, Depending upon the size & path of the lesion, appropriate post-appropriate post-EP EP surveillance is needed. surveillance is needed.

Gastrointest Endosc 62: 367 & 551, 2005.Gastrointest Endosc 62: 367 & 551, 2005. Current Opinion in Gastroenterol 20: 40, 2004.Current Opinion in Gastroenterol 20: 40, 2004. Gut 53: 381,2004.Gut 53: 381,2004.