Case provided by:
Dr. Adolfo Parra Blanco (who was consulted about this case by a colleague)
Hospital Universitario Central de Asturias, Oviedo, Spain

A type 0-IIa lesion in a Barrett’s esophagus was removed with multiband mucosectomy. After the first resection, the adjacent mucosa was suctioned into the cap and a rubber band was released. However, the second band was partly applied on the resection wound from the first resection, and the endoscopist could see the tissue from the first resection wound in the pseudopolyp that was formed (Figure a & b). Given his lack of experience with the multiband mucosectomy technique, the endoscopist did not resect the pseudopolyp, because he was afraid to perforate the esophagus.

The questions are:

- Could the resection have been finished without perforating the esophagus?

- Is there a risk on development of a delayed perforation, since the rubber band is still in situ?

Suggestion provided on behalf of the RFA Academia training committee by:
Dr. Jacques Bergman
Dept. of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands

As long as the band stays on and doesn’t slip off immediately, the risk that there is muscular tissue captured in the band is really small if the patient has no history of anything that may have caused esophageal scarring.

Overlap is acceptable, and even advisable to prevent residual tissue bridges, as long as it is less than 25%. In case of doubts:

1) push gently with the edge of the cap onto the band so that any muscle tissue can slip out;

2) wait a bit longer and inflate the esophagus (has the same effect as pushing onto the band);

3) place and close the snare above the band.

A combination of the above measures always works.

In this case were the psuedopolyp with the band was left in place, part of the tissue encaptured may partially slip out, the other part will necrose and fall of. This may be a good approach for treating patients with lesions on the top of esophageal varices. In this case I think I would have used the measures 1-3 to resect the lesion.