CONSENT EMR

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Your doctor has discussed with you in detail the greater risks associated with an endoscopic mucosal resection (EMR) in the gastrointestinal tract. These include:

1. Perforation – this may be able to be treated at the time of the procedure with metal clips or you may require surgery to treat this complication. Surgery does have its own risks and would only be undertaken if considered absolutely necessary to prevent further complications associated with any perforation.

2. Bleeding – this may be either immediate or delayed (up to 7 days after the procedure). In either case hospital admission, blood transfusion, repeat procedure (to control bleeding) or surgery may be necessary.

3. Oesophageal stenosis when an oesophageal EMR is performed. This may lead to significant swallowing problems requiring one or more oesophageal dilatations. Sometimes an oesophageal stent may be required.

4. As a result of these complications or their treatment there is a small chance of death. This small risk is associated with all medical or surgical procedures of this type.

However I also understand that there are significant benefits associated with this procedure. These include:

1. The removal of a polyp (or growth) which can otherwise turn into cancer.

2. The ability to have this procedure done as an outpatient. This allows me to avoid the extra time, cost and risk involved with elective surgery and hospital admission. Until EMR was available I have been advised that elective surgery was the only way to manage these growths.

I understand and accept these risks which have been clearly explained to me.

NAME:………………………………………….. DATE:…………………..

SIGNATURE:……………………………………………………