Endoscopic mucosal resection (EMR) is a minimally invasive technique used to remove irregular tissue from the digestive tract. It involves using an endoscope, a long, narrow tube equipped with a light, video camera, and surgical instruments, to access and remove suspect tissue or polyps from the esophagus, stomach, small intestine, large intestine (colon), or rectum. Because EMR is less invasive than traditional surgery, it generally carries fewer health risks and lower costs. However, proper post-procedure care, including dietary modifications, is crucial for optimal healing and recovery.
Understanding Endoscopic Mucosal Resection (EMR)
EMR is a procedure performed by a gastroenterologist to remove irregular tissues from the lining of the digestive tract without making cuts through the skin or removing a part of the gut. During EMR of the upper digestive tract, healthcare professionals pass the endoscope down the throat. The endoscope is equipped with a light, video camera, and other tools. EMR mainly is used as a treatment. It's also used to collect tissue for lab testing.
Why EMR is Performed
EMR gives specialists access to areas of diseased tissue about the size of a penny-four or five times larger than a typical biopsy. Traditionally, early-stage or precancerous growth would require surgery where a more sizeable piece of the stomach, esophagus, or intestines would have to be removed along with the growth. With EMR, the patient can have the growth removed through a non-surgical, minimally invasive approach.
The EMR Procedure
During EMR, a specially designed endoscope or colonoscope removes suspect tissue or polyps from the esophagus or colon. The tissue or polyp is first injected with a solution that raises a blister, allowing the doctor to remove the tissue without damaging the rest of the esophagus or colon. Suction is then used to further lift the growth up and away from surrounding tissue. A thin wire loop is slipped over the tissue, and an electric current is passed through the wire. This cuts the growth and helps to seal the wound.
Preparation for EMR
Preparation for an endoscopic mucosal resection, in large part, depends upon where the growth lies and what type of endoscopy (upper endoscopy or colonoscopy) will be performed. Generally, no eating or drinking is allowed for at least 4 to 8 hours before the procedure. Smoking and chewing gum are also prohibited during this time. Patients should tell their doctor about all health conditions they have-especially heart and lung problems, diabetes, and allergies- and all medications they are taking.
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What to Expect After the Procedure
After the procedure, patients are moved to a recovery room where they wait about an hour for the sedative to wear off. During this time, patients may feel abdominal pain, bloating, or nausea. Patients will likely feel tired and should plan to rest for the remainder of the day. The doctor will often share results with the patient after the sedative has worn off.
General Dietary Recommendations After EMR
In general, most of the gastrointestinal function has begun to recover by the second to third day after the EMR procedure, which is commonly referred to as "ventilation". At this point, except for some patients with special conditions, most patients can start enteral nutrition, which is referred to as eating. The gastrointestinal function began to recover after ventilation, and it needs to be recovered slowly due to surgical trauma. So, there is a slow transition process of eating, and patients should not eat as freely as they did before the surgery.
Initial Diet: Liquid Foods
In general, the diet process after the intestinal function is recovered after the EMR procedure should start with liquid food and then gradually transition to semi-liquid food until normal food. Liquid food is a type of food that is in a liquid state, which can be melted into liquid in the mouth. It is easier to swallow and digest than semi-liquid food. Examples of liquid foods include:
- Vegetable soup
- Tomato juice
- Fresh fruit juice
- Boiled fruit water
- Fruit tea
- Chicken soup
- Meat soup
- Liver soup
The time of eating liquid foods can be adjusted according to the recovery of individuals' gastrointestinal tract. If there are no special circumstances, the process usually lasts one to two days.
Transition to Semi-Liquid Foods
Semi-liquid food is a type of food that is relatively thin, easy to digest and chew, which contains less crude fiber, and it has a semi-liquid state without strong stimulation. After the transition of eating liquid food, the gastrointestinal function has been further recovered and gradually returned to the original stomach movement state. At this point, patients can gradually start to eat semi-liquid foods, which are commonly referred to as digestible foods. Examples of semi-liquid foods include:
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- Steamed egg
- Soft tofu
- Tofu pudding
- Fruit puree
- Ripe banana
- Vegetable puree
- Thin shredded vegetable leaves
- Minced meat
- Fish fillet
The duration of the procedure varies according to the duration of different surgeries.
Gradual Return to Normal Diet
After earlier adjustment of gastrointestinal function, the diet can gradually transit to a normal diet and return to their previous diet state. However, for the consideration of health, overeating should be avoided appropriately.
Solid vs. Liquid Diet After Gastric Neoplasm ESD: A Randomized Controlled Trial
A prospective pilot randomized controlled trial investigated the effects of solid versus liquid diets on patients undergoing endoscopic submucosal dissection (ESD) for gastric neoplasms. Patients were randomly assigned to either a solid diet group (n = 50) or a liquid diet group (n = 50).
Study Design
The day after ESD, endoscopy was performed in all patients to evaluate the ulcer surface based on the modified Forrest classification, which has predictive value for peptic ulcer rebleeding. This approach differentiates ulcers with spurting arterial hemorrhage (Forrest Ia) from those with oozing hemorrhage (Forrest Ib), a visible vessel (Forrest IIa), adherent clot (Forrest IIb), hematin on the ulcer base (Forrest IIc), or clean ulcer base (Forrest III). Hemostasis was performed for patients with ulcer surfaces rated Forrest Ia and Ib, and endoscopy was performed the next day for ulcer reevaluation. For patients rated Forrest IIa-III, hemostasis was performed as needed, and the patient resumed on oral intake the next day.
After confirmation of hemostasis, patients were randomized, on a 1: 1 basis, to either the solid or the liquid diet using the envelope method. Patients in the solid diet group were started on rice porridge and solid side dishes the day after hemostasis confirmation until discharge. In contrast, patients in the liquid diet control group were started on a liquid diet the day after hemostasis confirmation and were gradually introduced to increasingly solid foods until discharge.
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Study Results
Delayed bleeding occurred in the solid diet group (2%) but not in the liquid diet group. The QOL evaluation using the European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-STO22 showed a better score in the solid diet group. The patients who felt dietary restriction at discharge was of a larger number in the liquid diet group (p = 0.019). More patients experienced appetite loss (p = 0.038), constipation (p = 0.022), and dietary restriction (p = 0.037) in the liquid diet group during hospitalization.
Implications of the Study
This study suggests that while a liquid diet may reduce the risk of delayed bleeding, a solid diet (starting with rice porridge) may improve the quality of life and reduce the incidence of appetite loss, constipation, and dietary restriction during hospitalization.
Additional Considerations
- Medications: Patients should tell their doctor about all health conditions they have, especially heart and lung problems, diabetes, and allergies, and all medications they are taking. Your healthcare professional may ask you to stop taking some medicines for a short time before EMR.
- Follow-up Exams: Usually, you get a follow-up exam 3 to 12 months after your endoscopic mucosal resection. That way, your healthcare team can make sure the entire lesion was removed.
- Driving: Driving is not permitted for 24 hours after the procedure to allow sedatives time to completely wear off.
Potential Complications After EMR
Some results from the procedure are available immediately after the procedure. The doctor will often share results with the patient after the sedative has worn off. Bleeding can occur from the endoscopic mucosal but such bleeding often stops on its own or can be controlled through the procedure. Perforation (a hole or a deep tear in the lining of the colon or rectum) is another complication and may require surgery to repair. Injury to other organs such as the spleen can occur, but is very rare.
When to Seek Medical Attention
You'll also receive written instructions about when to call your healthcare professional or get emergency care after the EMR. It’s normal to have a small amount of bleeding from your rectum. There should be no more than a few drops of blood, and the bleeding should stop within 24 hours after your procedure.
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