Delayed specimen collection may artifactually damage the mucosal surface in endoscopic mucosal resection specimens from Barrett’s esophagus

Endoscopic mucosal resection (EMR) has become the standard of care for non-advanced Barrett’s neoplasia; however, surface mucosal damage/artifact is a common observation in EMR specimens. Because surface maturation is an important morphologic consideration when analyzing dysplasia, this artifact can be problematic in selected cases. The exact cause of this mucosal surface damage has not been clearly delineated. We hypothesize that delayed specimen retrieval may be one cause of the mucosal surface damage observed in Barrett’s EMR specimens. From the pathology archives of 2 institutions, 46 EMR specimens for dysplasia arising in Barrett’s esophagus were retrieved. In 26 cases, the endoscopists immediately removed each portion of resected mucosa and placed it in fixative. In 20 other cases, the resected mucosal fragments were allowed to fall into the stomach and were retrieved at the end of the procedure. All the cases were reviewed by at least 2 gastrointestinal pathologists. Surface detachment (assessing mechanical injury related to the resection devices) and surface chemical injury (assessing acid/enzymatic injury from immersion in gastric contents) were scored in a semi-quantitative manner and analyzed with the Fisher’s exact test. The specimens that were collected immediately upon resection demonstrated significantly less surface chemical injury (acid/enzymatic damage) compared to those with delayed collection (p=0.001). The degree of mechanical detachment was similar between the 2 groups (p=0.2). In conclusion, delayed specimen collection may cause significant mucosal surface damage and artifact in Barrett’s EMR specimens. It is important to raise awareness of this avoidable pitfall among both endoscopists and pathologists.