Dept. of Gastroenterology at PACE Hospitals, is equipped with advanced Third-Space Endoscopy, The SpyGlass® Direct Visualization System and Laparoscopic surgery equipment to perform complex and supra-major precancerous and cancerous conditions of gastrointestinal (GI) tract.
Our team of the Best Medical Gastroenterologist in Hyderabad, Telangana, India; are having extensive experience in performing endoscopic Resection and third space endoscopy techniques such as peroral endoscopic myotomy (POEM), endoscopic submucosal dissection (ESD), endoscopic mucosal resection (EMR) and submucosal tunneling endoscopic resection (STER) to treat conditions of achalasia cardia, Barrett’s esophagus etc.
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Pace Hospitals
Hitech City and Madinaguda
Hyderabad, Telangana, India.
Thank you for contacting us. We will get back to you as soon as possible. Kindly save these contact details in your contacts to receive calls and messages:-
Appointment Desk: 04048486868
Whatsapp: 7842171717
Regards,
Pace Hospitals
Hitech City and Madinaguda
Hyderabad, Telangana, India.
Etymologically, endoscopic describes the process or the usage of
endoscopy (endo – “within” and scopy – “to see” in Greek). Submucosal dissection describes the process of cutting at the level of submucosa.
An Endoscopic submucosal dissection (ESD) procedure is a minimally invasive procedure that is used to dissect (cut) and remove the tumours which are formed under the lining of the gastrointestinal tract (submucosal layer).
During the ESD procedure, the doctor uses an endoscope (flexible tube-like tool with a camera) which assists in the resection of precancerous and cancerous tissues found in the gastrointestinal (GI) tract. Depending upon the location of the tumour, the endoscope could be either inserted through the buccal region (the mouth) or through the anal region.
It is important to note that since the complete removal of these tumours through other methods could prove difficult, ESD procedure could be a final solution as the formation of these tumours is at close quarters with the GI muscle tissue.
Due to the complexity of the procedure, accompanied by its rare occurrence, it is important for the patients to opt for a competent gastroenterologist doctors who are also skilled in interventional endoscopy, as general endoscopists may not be able to perform it.
Development of endoscopic submucosal dissection (ESD) technique is specialised procedure to resect larger tumours apart from obtaining higher rates of en-bloc resection than that of endoscopic mucosal resection. Endoscopic Submucosal Dissection (ESD) procedure is generally indicated for the following:
Medical gastroenterologists or surgical gastroenterologists who are also skilled in interventional endoscopy are usually the first preferred choice. Nevertheless, surgical oncologists and endoscopists with experience in interventional endoscopy could also be consulted.
Need for specialised training and the learning curve
Endoscopic Submucosal Dissection (ESD) procedure is a technically demanding procedure which requires substantial training to achieve competence; inadequate training compromises both patient safety and technical outcomes.
Before the gastroenterologist prescribes an endoscopic submucosal dissection (ESD) technique, the patient undergoes a thorough physical and clinical examinations. The gastroenterologist understands the previous medical issues both by performing these examinations and by imploring the patients about their previous major medical problems such as diabetes, hypertension, pregnancy etc.
In addition, current medications, especially the use of antiplatelet and anticoagulation agents and the presence of any allergic history of the patient, must be provided to the gastroenterologist.
The doctor examines the patient thoroughly, and only after absolute necessity endoscopic submucosal dissection technique is prescribed. Either the gastroenterologist or any personnel from the team thoroughly explains the procedure before obtaining written consent.
To understand the principle of endoscopic submucosal dissection technique, the division of the wall of the gastrointestinal tract must be understood. The mucosa and muscle are the principal layers existing in the wall of the gastrointestinal tract, which are attached by a loose connective tissue submucosa. It is within this submucosal tissue that gastric submucosal tumours and mesenchymal origin-stromal tumours originate.
Most people with early gastric cancer do not exhibit any noticeable symptoms. If gastric cancer screening is performed correctly, it is possible to discover the disease at an early stage. Unfortunately, people are frequently diagnosed with advanced stomach cancer because they were not checked for the disease.
Not just the discovery of the tumour but endoscopic submucosal dissection procedure also assists in removing it. Developed from an endoscopic resection (EMR) technique, the execution of ESD procedure is done in three steps:
Rising the spatial altitude of gastric cancers and any other polyps by lifting them up through injecting fluid underneath them for the process of clear dissection is the prime principle of endoscopic submucosal dissection.
The Endoscopic Submucosal Dissection (ESD) procedure is not done in the following:
Being one of the most complicated endoscopic procedures, endoscopic submucosal dissection involves incising (cutting) the mucosa (soft tissue lining the body's canals) and directly dissecting the submucosal layer after injection. It is one of the reasons for its scarcity, and therefore, it is necessary that the patients must opt for the best gastroenterologists skilled in interventional endoscopy rather than approaching mere general endoscopists.
Perforation risks
Despite being the expert, at times, interventional gastroenterologists do face difficulty in executing the task safely due to the depth of technical difficulties it could create and the risks accompanying the procedure. Although being 2-6% in previous reports, perforation is one of the most common surgical complications. Perforation is a medical term to describe the hole (aperture) that develops through the wall of a body organ.
Careful selection and dissection of submucosal fibres
Good visualisation of the submucosal tissue is necessary to reduce the risks of perforation. Countertraction is a very useful method to make good visualisation during the dissection of submucosal fibres. There are various devices and methods to achieve countertraction, such as:
Although these methods effectively apply countertraction to the tissue, their rarity could be attributed to their complicated process. Gastroenterologists update themselves periodically on the current scientific trends.
A novel ESD technique was developed using the intragastric lifting method with a re-opening clip device which executes safer, easier, and less time-consuming ESD compared to the previous methods. By using this method, even general endoscopists may also be able to perform a safe ESD procedure.
Maintenance of submucosal fluid cushion
Gastroenterologists undertake various measures to even minimise the already abysmal perforation rates. By creating an adequate submucosal fluid cushion (SFC) between the lesion and the muscle layer, the risk of perforation can be prevented.
While submucosal injection of normal saline can be administered to obtain the effect, it has got its limitations of being rapidly absorbed, greatly limiting the duration of the window of gastroenterologists for endoscopic submucosal dissection technique. The other methods include:
Implementation of the best electrosurgical knives
While it is necessary to use the accustomed knife, it is also important to choose devices that suit the situation of treatment. Interventional gastroenterologist prefers to utilise the knives which have improved safety, such as IT knife, Hook knife, Flex knife etc.
The mucosectome is one such electrosurgical device that has been newly developed for ESD. Since the top of this device turns freely, it greatly assists the cutting wire in facing the proper direction. A Japanese study demonstrated its efficacy with no perforations and only minor bleeding in 9.8% of patients. Mucosectome can execute safer, easier, and less time-consuming ESD compared to previous methods. By using this device, general endoscopists may also be able to carry out ESD safely.
Although both Endoscopic Submucosal Dissection (ESD) and Endoscopic Mucosal Resection (EMR) procedure are used to locate and remove any early gastric cancers, lesions and polyps found in the gastrointestinal canal, there are certain differences which signify the efficacy of ESD procedure over the EMR procedure. Few of them are:
Parameter | Endoscopic Submucosal Dissection (ESD) | Endoscopic Mucosal Resection (EMR) |
---|---|---|
Definition | Injecting the submucosal layer with fluid or gel to dissect the plane and lift a lesion. Once a lesion is raised, it can be cut, reducing the perforation risk. | Resecting a lesion with a variety of techniques (suction, lift, underwater). Usually, the division plane is within the submucosa and often is not as precise. |
The extent of submucosal cutting | Deeper division of the tissues within the submucosal layer | Superficial cutting |
Recurrence rate | Approximately 1% | 6-10% but can be higher if lesions are removed in a piecemeal fashion |
Size limitations | Lesions of 2-3 cm diameter, occupying less than two-thirds of the oesophageal lumen | At most, 2-3 cm diameter and less than one-third the circumference of the oesophageal lumen |
Duration | More time consuming | Less time consuming |
Extent of sedation | As procedure duration could be longer, often the ESD team prefers general anaesthesia | EMR can often be performed under moderate sedation |
Post operative hospitalisation | Since ESD carries a higher risk of bleeding complications an overnight observation may be necessary | Majority of the EMR procedures can be done in ambulatory setting |
The Endoscopic Submucosal Dissection (ESD) procedure is technically demanding, which may cause a high frequency of complications, especially perforation and post-operative bleeding (delayed bleeding). The risk factors for perforation and post-operative bleeding during and after ESD technique of gastric neoplasms are:
Endoscopic submucosal dissection technique is associated with various complications, most importantly, bleeding and perforation, amongst others.
Perforation
Most of the perforations occur during the ESD procedure, ranging from 1.2% to 5.2% for gastric endoscopic submucosal dissection. Gastric perforation is higher in both the upper and middle thirds of the stomach when compared with the lower third of the stomach. It could be due to the thinner gastric wall in the former two locations than in the latter.
Bleeding
Bleeding complications could be:
In immediate bleeding, management plays a critical role. Since the diameter of the submucosal arteries in both the upper and middle thirds of the stomach is higher, it is common to expect a higher level of significant immediate bleeding in these parts when compared to the lower third of the stomach.
Delayed bleeding after ESD procedure could range from 0%-15.6%. It was found that delayed bleeding after the ESD procedure occurred more frequently in the lower and middle thirds of the stomach, which could be due to antral peristaltic activity and the alkaline effect of bile juice reflux. Antram is the lower part of the stomach. Peristalsis is the wavy movement generated in the gut to push the food down to the next compartment of the alimentary canal.
Other complications
The complications include:
In an open surgery traction can be easily applied with the use of second arm. As ESD procedure is not an open surgery, the inability of generating a traction poses a prime drawback.
To help generate the traction, various methods have been proposed and developed such as the clip-with-line method, the percutaneous traction method, the sinker-assisted method, the external forceps method, the internal-traction methods among various others.
The magnetic anchor technique (MAT) is one such method of generating traction.
Magnetic anchor guided - endoscopic submucosal dissection or the ESD MAT testing procedure demonstrated its potential benefits when compared to various other current traction methods.
This ESD MAT testing procedure does not interfere with any of the endoscopic procedures, unlike the double channel and outer-route methods. Unlike the percutaneous traction, clip-with-line, and sinker-assisted methods, the dynamic traction provided by ESD MAT testing procedure can change the direction of retraction through the movement of external magnet.
To examine the gastrointestinal organs, an endoscopy is performed with an endoscope - a long, thin tube that contains a small camera which is inserted into the body through the mouth or anus. Usually done as an outpatient procedure, it is prescribed to the patient only after a thorough examination by the doctor who notices a pattern of symptoms.
When people think of endoscopy, they typically think of a screening examination such as a colonoscopy for cancer surveillance etc. Nevertheless, endoscopies have evolved for a variety of indications, such as gastrointestinal bleeding and gastroesophageal reflux. In the earlier days, when endoscopy was still in infancy, the endoscopists could only view the anomaly (polyps, tumours etc.) as the devices lacked the technical harness and equipment. Of late, along with diagnostic uses, interventional/therapeutic uses are also incorporated into endoscopic procedures.
Despite the advancement of various endoscopic techniques, such as:
Endoscopic submucosal dissection (ESD) always has the edge over its predecessors and contemporaries as it is:
Frequently asked questions:
A minimally invasive procedure, the endoscopic submucosal dissection or ESD procedure utilises an endoscope (a long tube with a camera) to view and remove any lesions (precancerous and cancerous) which may form in the gastrointestinal tract. It involves lifting the lesion up by injecting fluid underneath its submucosal layer. Once raised, it is easier to get a clear cut when compared to endoscopic mucosal resection (EMR).
Yes. The endoscopic submucosal dissection procedure is safe when it is done by a skilled and experienced gastrointestinal surgeon adept in interventional endoscopy. It is reportedly safer than endoscopic mucosal resection (EMR) as the submucosal dissection procedure or ESD procedure showed great advantages of achieving en bloc resection, complete resection, curative resection, and lower local recurrence.
Yes. The endoscopic submucosal dissection procedure is very effective when it is done by an experienced gastrointestinal surgeon skilled in interventional endoscopy. A 2011 study found a distinct advantage of ESD over EMR in terms of clinical effectiveness and safety outcomes. Considering all the outcome benefits of ESD over EMR, ESD procedure could be the first choice for early gastric cancer treatment based on improved clinical outcomes and quality of life for the patients.
Through endoscopic knives the interventional gastroenterologists dissect the lesion/polyp. They prefer to utilise the knives with improved safety features such as IT knife, Hook knife, Flex knife etc.
The mucosectome is one such electrosurgical device that has been newly developed for ESD. A Japanese study demonstrated its efficacy with no perforations and only minor bleeding in 9.8% of patients.
Endoscopic mucosal resection (EMR) is a procedure which can be done to remove superficial masses of precancerous growths and early-stage cancer which line the digestive tract. While endoscopic submucosal dissection or ESD procedure also does the same, a clear cut can be obtained by this procedure with lesser rates of remission when compared to EMR.
Usually, five days is the norm. Nevertheless, it must be understood that since every patient is different, the recovery time could be either longer or shorter combined with various factors such as complications, comorbidities etc.
Bleeding and perforation are major risks of endoscopic submucosal dissection. The other risks include stenosis, aspiration pneumonia, air embolism and deep vein thrombosis.
The success rate of endoscopic submucosal dissection could be dependent on various factors and type of the polyp/lesion could also influence it. The complete resection rate for the endoscopic submucosal dissection in superficial oesophageal squamous cell carcinoma is 97.1%, while the 5-year overall survival rates were around 85–95%. Read the report
In colorectal ESD procedures, the perforation rate could be as high as 1.4%–20.4%. A 2016 meta-analysis demonstrated that the immediate perforation rates were 4.2% while the delayed perforation rates were 0.22 %. The majority of the immediate and delayed perforation rates were seen in Western countries when compared to Asian countries.
Around 2-8 cm lesions can be considered as a feasible size range. Nevertheless, lesions greater than 5 cm require piecemeal resection or at least dividing the lesion to allow dissection.
Endoscopic submucosal dissection cost in India, ranges vary from ₹ 1,25,000 to ₹ 1,50,000 (Rupees one lakh twenty-five thousand to one lakh fifty thousand). However, cost of Endoscopic Submucosal Dissection (ESD) Procedure in India vary in different private hospitals in different cities.
Endoscopic submucosal dissection cost in Hyderabad ranges vary from ₹ 1,15,000 to ₹ 1,28,000 (Rupees one lakh fifteen thousand to one lakh twenty-eight thousand). However, cost of Endoscopic Submucosal Dissection (ESD) Procedure in Hyderabad depends upon the multiple factors such as patient age, condition, length of stay in hospital and CGHS, ESI, EHS, insurance or corporate approvals for cashless facility.
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