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A novel clinical application for endoscopic mucosal clipping
A novel clinical application for endoscopic mucosal clipping Richard L. Weyman, MD Satish S. C. Rao, MD, PhD
Background: Endoscopic hemoclipping has been shown to be effective in the treatment of gastrointestinal bleeding. Here we describe a novel clinical application for endoscopic application of metal clips. Methods: A middle-aged man with inoperable squamous cell cancer of the esophagus underwent per protocol a barium esophagogram to document tumor margins prior to radiation therapy. This study failed to localize the full extent of the tumor. At endoscopy, the tumor margins were clearly visible. To delineate the proximal and distal margins, detachable metallic clips were passed through the accessory channel of a standard endoscope and using a clip fixing device the clips were placed at each level. Subsequently, a chest xray was obtained. Results: Placement of mucosal clips facilitated radiotherapy. Conclusions: Endoscopic mucosal clipping may serve as a useful technique for localizing or marking gastrointestinal lesions, especially for demarcating a precise radiation field when conventional techniques fail. The hemoclipping application device has previously been described.1 Reports pertain mainly to its use as a means of stopping refractory gastrointestinal bleeding. In this report we describe a new application. To our knowledge this is the first report that describes this technique for delineating a gastrointestinal tumor prior to radiation therapy. PATIENT AND METHOD A 51-year-old man presented with epigastric pain, weight loss, and dysphagia. Upper endoscopy revealed a 4 cm long, squamous cell carcinoma in the distal esophagus. After staging with endoscopic ultrasound, CT of the
Received April 15, 1998. For revision July 2, 1998. Accepted October 7, 1998. From the Division of Gastroenterology/Hepatology, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa. Reprint requests: Satish S. C. Rao, MD, FRCP(UK), PhD, Division of Gastroenterology/Hepatology, Univ. of Iowa Hospitals and Clinics, 200 Hawkins Dr., Iowa City, IA 52241. Copyright © 1999 by the American Society for Gastrointestinal Endoscopy 0016-5107/99/$8.00 + 0 37/69/94985 522
GASTROINTESTINAL ENDOSCOPY
Figure 1. A barium swallow radiograph that failed to identify any tumor. abdomen, and exploratory laparotomy, the tumor was classified as T2 N1 M1. After the exploratory laparotomy, his hospital course was complicated by pseudomonas pneumonia and respiratory support with a ventilator was required. He was deemed to not be a candidate for surgical resection of the tumor and was referred for radiotherapy. His past medical history was significant for a left upper lobe pulmonary sarcoma in 1985 for which he underwent surgical resection and radiation therapy. In preparation for radiation therapy a barium esophagogram was obtained. This failed to demonstrate the tumor or its margins (Fig. 1). Because accurate delinVOLUME 49, NO. 4, PART 1, 1999
A novel clinical application for endoscopic mucosal clipping
R Weyman, S Rao
Figure 2. Endoscopic view of the distal esophagus shows a nodular, raised growth extending from 12 o’clock to 6 o’clock. The proximal margin of the tumor can be seen at the top of the figure. A mucosal clip marking the distal margin of the tumor can be seen. eation of the tumor margin is critical for successful radiation therapy, upper endoscopy was performed. The margins of the tumor were readily identified and one metallic clip (HX-3/4 Clip Fixing Device; Olympus America, Inc., Melville, N.Y.) was placed at the proximal margin and another at the distal margin of the tumor (Fig. 2). A chest x-ray (Fig. 3) was then obtained to document the location of the metallic clips.
RESULTS Although the mucosal clips were no longer detectable by chest x-ray approximately 1 month after endoscopic placement, ample time was available for selection of a precise radiation field. Subsequently, the patient has received a total radiation 3000 cGy administered over 12 courses. DISCUSSION Two decades ago Hayashi et al.2 introduced the technique of endoscopic hemostasis using a metallic clip. Initial results were discouraging, however, in part due to poor retention of the metallic clip and the technical complexity of clip application. More recently, sophisticated clipping devices and a variety of clips have become available.1,3 The newer metallic clips are not only easier to place but also cause less tissue trauma and are safe.1,3 To our knowledge this is the first report of endoscopic mucosal clipping to facilitate radiation therapy. The accurate localization of a gastrointestinal lesion for either preoperative or preradiotherapy purposes may ultimately improve the diagnostic and therapeutic outcomes and reduce morbidity, VOLUME 49, NO. 4, PART 1, 1999
Figure 3. Chest x-ray shows mucosal clips at proximal and distal margins of the tumor (arrows). Multiple surgical clips along with fibrosis and scarring of the left lung secondary to previous pulmonary sarcoma and a permanent tracheostomy can also be seen.
especially when the lesions are small, as illustrated by our case. In addition, our patient had radiation therapy 12 years earlier in a location adjacent to the current proposed radiation field (Fig. 3). Hence, precise delineation of the tumor margins was of paramount importance. The standard method for outlining the radiation field for esophageal carcinoma palliation is a double contrast esophagogram or CT with oral contrast.4 In our patient the double contrast esophagogram failed to delineate the tumor margins. We believe our experience broadens the indications for endoscopic clipping. With average dexterity, this technique can be mastered by most gastroenterologists. In our patient it facilitated a more accurate approach to the treatment of a gastrointestinal lesion while preventing unnecessary and excessive radiation to adjacent tissues. Endoscopically placed mucosal clips have been utilized for purposes other than radiation therapy, including intraoperative colonoscopy with laparoscopic placement of serosal clips to define tumor margins.5 But unlike mucosal clips, serosal clips tend to become dislodged and are difficult to visualize.5 An alternative endoscopic technique to delineate tumor margins for palliative therapy is subGASTROINTESTINAL ENDOSCOPY
523
mucosal injection of contrast using a sclerotherapy needle.6 Potential problems with this technique include dissipation of the contrast material through the submucosa6 or hypersensitivity to the contrast material. Other applications for endoscopic mucosal clipping include temporary anchoring of manometry probes to the colonic mucosa for manometry studies, anchoring feeding tubes,7 and accurate placement of an esophageal prosthesis.6 In conclusion, our experience suggests that in addition to hemostasis, endoscopic mucosal clipping has other potential uses including delineation of gastrointestinal malignant lesions prior to radiotherapy. REFERENCES 1. Ohta S, Yukioka T, Ohta S, Miyagatani Y, Matsuda H, Shimazaki S. Hemostasis with endoscopic hemoclipping for
524
GASTROINTESTINAL ENDOSCOPY
2.
3.
4.
5.
6.
7.
severe gastrointestinal bleeding in critically ill patients. Am J Gastroenterol 1996;91:701-4. Hayashi T, Yonezawa M, Kuwabara T, Kudoh I. The study on staunch clip for the treatment by endoscopy. Gastroenterol Endosc 1975;17:92-101. Binnmoeller KF, Thonke F, Soehendra N. Endoscopic hemoclip treatment for gastrointestinal bleeding. Endoscopy 1993;25:167-70. Perez C, Brady L. Principles and practice of radiation oncology. 2nd ed. Philadelphia: Lippincott-Raven Publishers; 1992. p. 856-57. Kim SH, Milsom JW, Church JM, Ludwig KA. Perioperative tumor localization for laparoscopic colorectal surgery. Surg Endosc 1997;11:1013-6. Raijman I, Kortan P, Haber GB, Marcon NE. Contrast injection to identify tumor margins during esophageal stent placement. Gastrointest Endosc 1994;40:222-4. Faigel DO, Kadish SL, Ginsberg GG. The difficult to place feeding tube: successful endoscopic placement using a mucosal clip. JPEN J Parenter Enteral Nutr 1996;20:306-8.
VOLUME 49, NO. 4, PART 1, 1999
Background: Endoscopic hemoclipping has been shown to be effective in the treatment of gastrointestinal bleeding. Here we describe a novel clinical application for endoscopic application of metal clips. Methods: A middle-aged man with inoperable squamous cell cancer of the esophagus underwent per protocol a barium esophagogram to document tumor margins prior to radiation therapy. This study failed to localize the full extent of the tumor. At endoscopy, the tumor margins were clearly visible. To delineate the proximal and distal margins, detachable metallic clips were passed through the accessory channel of a standard endoscope and using a clip fixing device the clips were placed at each level. Subsequently, a chest xray was obtained. Results: Placement of mucosal clips facilitated radiotherapy. Conclusions: Endoscopic mucosal clipping may serve as a useful technique for localizing or marking gastrointestinal lesions, especially for demarcating a precise radiation field when conventional techniques fail. The hemoclipping application device has previously been described.1 Reports pertain mainly to its use as a means of stopping refractory gastrointestinal bleeding. In this report we describe a new application. To our knowledge this is the first report that describes this technique for delineating a gastrointestinal tumor prior to radiation therapy. PATIENT AND METHOD A 51-year-old man presented with epigastric pain, weight loss, and dysphagia. Upper endoscopy revealed a 4 cm long, squamous cell carcinoma in the distal esophagus. After staging with endoscopic ultrasound, CT of the
Received April 15, 1998. For revision July 2, 1998. Accepted October 7, 1998. From the Division of Gastroenterology/Hepatology, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa. Reprint requests: Satish S. C. Rao, MD, FRCP(UK), PhD, Division of Gastroenterology/Hepatology, Univ. of Iowa Hospitals and Clinics, 200 Hawkins Dr., Iowa City, IA 52241. Copyright © 1999 by the American Society for Gastrointestinal Endoscopy 0016-5107/99/$8.00 + 0 37/69/94985 522
GASTROINTESTINAL ENDOSCOPY
Figure 1. A barium swallow radiograph that failed to identify any tumor. abdomen, and exploratory laparotomy, the tumor was classified as T2 N1 M1. After the exploratory laparotomy, his hospital course was complicated by pseudomonas pneumonia and respiratory support with a ventilator was required. He was deemed to not be a candidate for surgical resection of the tumor and was referred for radiotherapy. His past medical history was significant for a left upper lobe pulmonary sarcoma in 1985 for which he underwent surgical resection and radiation therapy. In preparation for radiation therapy a barium esophagogram was obtained. This failed to demonstrate the tumor or its margins (Fig. 1). Because accurate delinVOLUME 49, NO. 4, PART 1, 1999
A novel clinical application for endoscopic mucosal clipping
R Weyman, S Rao
Figure 2. Endoscopic view of the distal esophagus shows a nodular, raised growth extending from 12 o’clock to 6 o’clock. The proximal margin of the tumor can be seen at the top of the figure. A mucosal clip marking the distal margin of the tumor can be seen. eation of the tumor margin is critical for successful radiation therapy, upper endoscopy was performed. The margins of the tumor were readily identified and one metallic clip (HX-3/4 Clip Fixing Device; Olympus America, Inc., Melville, N.Y.) was placed at the proximal margin and another at the distal margin of the tumor (Fig. 2). A chest x-ray (Fig. 3) was then obtained to document the location of the metallic clips.
RESULTS Although the mucosal clips were no longer detectable by chest x-ray approximately 1 month after endoscopic placement, ample time was available for selection of a precise radiation field. Subsequently, the patient has received a total radiation 3000 cGy administered over 12 courses. DISCUSSION Two decades ago Hayashi et al.2 introduced the technique of endoscopic hemostasis using a metallic clip. Initial results were discouraging, however, in part due to poor retention of the metallic clip and the technical complexity of clip application. More recently, sophisticated clipping devices and a variety of clips have become available.1,3 The newer metallic clips are not only easier to place but also cause less tissue trauma and are safe.1,3 To our knowledge this is the first report of endoscopic mucosal clipping to facilitate radiation therapy. The accurate localization of a gastrointestinal lesion for either preoperative or preradiotherapy purposes may ultimately improve the diagnostic and therapeutic outcomes and reduce morbidity, VOLUME 49, NO. 4, PART 1, 1999
Figure 3. Chest x-ray shows mucosal clips at proximal and distal margins of the tumor (arrows). Multiple surgical clips along with fibrosis and scarring of the left lung secondary to previous pulmonary sarcoma and a permanent tracheostomy can also be seen.
especially when the lesions are small, as illustrated by our case. In addition, our patient had radiation therapy 12 years earlier in a location adjacent to the current proposed radiation field (Fig. 3). Hence, precise delineation of the tumor margins was of paramount importance. The standard method for outlining the radiation field for esophageal carcinoma palliation is a double contrast esophagogram or CT with oral contrast.4 In our patient the double contrast esophagogram failed to delineate the tumor margins. We believe our experience broadens the indications for endoscopic clipping. With average dexterity, this technique can be mastered by most gastroenterologists. In our patient it facilitated a more accurate approach to the treatment of a gastrointestinal lesion while preventing unnecessary and excessive radiation to adjacent tissues. Endoscopically placed mucosal clips have been utilized for purposes other than radiation therapy, including intraoperative colonoscopy with laparoscopic placement of serosal clips to define tumor margins.5 But unlike mucosal clips, serosal clips tend to become dislodged and are difficult to visualize.5 An alternative endoscopic technique to delineate tumor margins for palliative therapy is subGASTROINTESTINAL ENDOSCOPY
523
mucosal injection of contrast using a sclerotherapy needle.6 Potential problems with this technique include dissipation of the contrast material through the submucosa6 or hypersensitivity to the contrast material. Other applications for endoscopic mucosal clipping include temporary anchoring of manometry probes to the colonic mucosa for manometry studies, anchoring feeding tubes,7 and accurate placement of an esophageal prosthesis.6 In conclusion, our experience suggests that in addition to hemostasis, endoscopic mucosal clipping has other potential uses including delineation of gastrointestinal malignant lesions prior to radiotherapy. REFERENCES 1. Ohta S, Yukioka T, Ohta S, Miyagatani Y, Matsuda H, Shimazaki S. Hemostasis with endoscopic hemoclipping for
524
GASTROINTESTINAL ENDOSCOPY
2.
3.
4.
5.
6.
7.
severe gastrointestinal bleeding in critically ill patients. Am J Gastroenterol 1996;91:701-4. Hayashi T, Yonezawa M, Kuwabara T, Kudoh I. The study on staunch clip for the treatment by endoscopy. Gastroenterol Endosc 1975;17:92-101. Binnmoeller KF, Thonke F, Soehendra N. Endoscopic hemoclip treatment for gastrointestinal bleeding. Endoscopy 1993;25:167-70. Perez C, Brady L. Principles and practice of radiation oncology. 2nd ed. Philadelphia: Lippincott-Raven Publishers; 1992. p. 856-57. Kim SH, Milsom JW, Church JM, Ludwig KA. Perioperative tumor localization for laparoscopic colorectal surgery. Surg Endosc 1997;11:1013-6. Raijman I, Kortan P, Haber GB, Marcon NE. Contrast injection to identify tumor margins during esophageal stent placement. Gastrointest Endosc 1994;40:222-4. Faigel DO, Kadish SL, Ginsberg GG. The difficult to place feeding tube: successful endoscopic placement using a mucosal clip. JPEN J Parenter Enteral Nutr 1996;20:306-8.
VOLUME 49, NO. 4, PART 1, 1999