D0228 - Endoscopic Management of Esophageal Cancer in a Patient with Decompensated Cirrhosis: The Importance of Multidisciplinary Collaboration and Peri-Procedure Planning in Complex Clinical Scenarios

Tuesday, October 25, 2022

10:00 AM – 12:00 PM ET

Location: Crown Ballroom

Has Audio

Presenting Author(s)

Sarah Enslin, PA-C

University of Rochester Medical Center
Rochester, NY

Sarah Enslin, PA-C, Gopal Ramaraju, MD, Vivek Kaul, MD, FACG
University of Rochester Medical Center, Rochester, NY

Introduction: Endoscopic therapy is effective for management of early esophageal cancer (EC), however serious complications such as bleeding and perforation can occur. Patient selection, optimization of co-morbidities and peri-procedure management help mitigate risk and improve patient outcomes. We present a patient with decompensated cirrhosis who required complex peri-procedure planning prior to endoscopic treatment of early EC.

Case Description/Methods: A 71-year male with decompensated cirrhosis (portal hypertension, esophageal varices, ascites) and recent DVT on apixaban was found to have a 1cm raised focal lesion at the GEJ; biopsies revealed high-grade dysplasia (HGD). He was referred for endoscopic mucosal resection (EMR). After extensive discussion with hematology, patient was admitted for anticoagulation management with intravenous (IV) heparin. EGD confirmed an 8mm nodule at the GEJ (Image 1A,B,C). Grade 3 non-bleeding esophageal varices were noted at the GEJ and in the distal esophagus, prohibiting safe EMR. Biopsies again showed HGD. After multidisciplinary tumor board discussion, a transjugular portosystemic shunt (TIPS) was performed to decompress the portal system and reduce bleeding risk from the planned EMR.

Doppler ultrasound a few weeks later confirmed patent TIPS. Repeat diagnostic EGD showed decompression of varices. EUS revealed a mucosal lesion with no lymphadenopathy. Biopsy revealed intramucosal adenocarcinoma. Based on this evaluation and after detailed discussion with the patient, EMR was planned with appropriate anticoagulation management. En-bloc multiband mucosectomy was performed (image 1D,E). Intraprocedural bleeding was controlled with band ligation and hemostatic spray (Image 1F). Patient remained inpatient for observation on octreotide and IV pantoprazole drip without further bleeding. Apixaban 2.5mg was resumed on day 3 and he was discharged home on acid suppression. Pathology confirmed well-differentiated adenocarcinoma, pT1a. Tumor board discussion recommended continued endotherapy (cryotherapy) to the residual dysplastic Barrett’s mucosa which he is tolerating well.

Discussion: Endoscopic treatment is effective for the management of early EC. However, when complex scenarios present in an elderly frail patient, multidisciplinary collaborative management and stepwise risk-mitigation strategies need to be in place to minimize morbidity and maximize success (table 1). Tumor board and shared decision making are key patient centric strategies that reflect best practice.

Figure: Image 1 - A: Nodular distal esophageal lesion; B: Lesion in high-definition white light endoscopy (HDWLE); C: Lesion in narrow band imaging (NBI), D: Band placed at the base of the lesion, E: EMR defect, F: Hemostatic spray was used to achieve hemostasis of an area of focal bleeding after EMR

Pre-procedure consultation (nonemergent diagnostic/elective procedures)

Pre-procedure planning (labs, imaging)

Optimization of treatment for co-morbidities

Anesthesia consultation

Detailed high-risk informed consent

Shared decision making

Multidisciplinary GI tumor board discussion

Medical record documentation

Guideline-based anti-thrombotic management

Appropriate procedure back-up and support (IR, surgery, radiology, critical care)

Table: Table 1: Risk Mitigation Strategies in Complex Endoscopy Practice – Best Practice Principles

Disclosures:

Sarah Enslin indicated no relevant financial relationships.

Gopal Ramaraju indicated no relevant financial relationships.

Vivek Kaul: Ambu – Consultant. CDX – Consultant. Cook Medical – Consultant. Motus GI – Consultant. Steris Corp – Consultant.

Sarah Enslin, PA-C, Gopal Ramaraju, MD, Vivek Kaul, MD, FACG. D0228 - Endoscopic Management of Esophageal Cancer in a Patient with Decompensated Cirrhosis: The Importance of Multidisciplinary Collaboration and Peri-Procedure Planning in Complex Clinical Scenarios, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.