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Endoscopic Surgery: A revolution in treatment in gastrointestinal disorders

Pace Hospitals

Endo-Surgery : A New Frontier In Therapeutic Endoscopy

Since its inception about 60 years ago, endoscopy has been traditionally used to visualize the lumen of the gastrointestinal tract. Whilst, for decades endoscopy has allowed removal of lesions such as polyps without incisions, for safety reasons, these procedures were limited to the superficial layers of the gastrointestinal tract. However, this decade has been an exciting time in the field of endoscopy. With rapid developments in safe endoscopic suturing devices, from being primarily a diagnostic field with minor therapeutic possibilities, endoscopy has metamorphosised to minimally invasive scar-less endosurgery.

About a decade ago surgery was the only treatment option available for certain conditions. Endo- surgery now offers a safe alternative. With procedures such as per-oral endoscopic myotomy (POEM), sub mucosal endoscopy tunneling endoscopic resection (STER) for submucosaltumours, endoscopic bariatric sleeve gastroplasty (ESG), endo-surgery is the new frontier in therapeutic endoscopy.

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What are the types of endo-surgery that are currently available?

Endo surgery or third space endoscopy, also commonly referred as submucosal endoscopy, is founded on the principle that the deeper layers of the gastrointestinal (GI) tract can be accessed by tunneling in the submucosal space without compromising the integrity of the overlying mucosa.

Procedures in this area include :

POEM - Per oral endoscopic myotomy for Achalasia
ESD – Endoscopic submucosal dissection for resection of tumours
STER – Submucosal tunneling endoscopic resection for resection of tumours
ESG – Endoscopic sleeve gastroplasty for weight reduction

What is Achalasia and what are the advantages of POEM procedure?

Peroral Endoscopic Myotomy (POEM) Procedure

ACHALASIA is a debilitating condition of dysfunctional swallow due to the absence of oesophageal motility and the failure of relaxation of the lower oesophageal sphincter. There is no medical treatment for his condition. Until now the only treatments available have been balloon dialation (with a high recurrence rate) or Heller’s myotomy (laproscopic surgical procedure).

The advent of POEM has changed the playing field in this condition. POEM is a minimally invasive intervention with results comparable to surgery and better than that of balloon dialation.

The advantages of POEM over surgery:

Scarless procedure
Shorter operative time
Requires lesser sedation
Less blood loss
Shorter hospital stay
Offers ability to perform a longermyotomy
No risk of post procedure wound infection
Effective in patients who fail surgical treatment

What is EMR/ ESD/ STER?

ESD (Endoscopic submucosal dissection for resection) and STER (Submucosal tunneling endoscopic resection)

These are endosurgical procedures for resection of early tumours/cancers. Whilst EMR has been part of routine therapeutic endoscopy over a decade, ESD and STER are the newer techniques which enable safe “en bloc” resection of larger and deeper lesions where previously the only option was surgery.

EMR Indications:

Superficial lesion in Barrett’s esophagus
Early gastric mall gastric lesion
Non-depressed colorectal lesions

ESD Indications:

Larger and poorly lifting lesions in Barretts mucosa
Early squamous cell cancers of the esophagus(limited to the superficial layers)
Early gastric cancers
Selective lesions in the Colorectum

STER indications:

Submucosal tumors (SMT) are tumors that generally does not manifest clinical symptoms; because of which, the detection rate is low. SMTs are primarily benign, although some are malignant tumors. Thus, a complete resection needs to be performed to obtain the pathological diagnosis. Surgery has been the primary treatment for esophageal SMTs. Though ESD is an option it is associated with a risk of perforation (causing a hole). STER has been established as a safe technique which enables enbloc removal of these lesions.

These indications can be expanded to include deeper cancers in elderly patients with co-morbidities who have either declined surgery or in whom the risk of surgery is very high.

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What are the advantage of EMR/ESD/STER over surgery?

In general, in carefully selected cases ESD/EMR /STER is the treatment of choice due to

Shorter operative time
Shorter hospital stay
Lower complication rates
Similar oncologic outcomes and survival compared to surgery

What is Endoscopic Sleeve Gastroplasty (ESG)?

Obesity is the current epidemic and it is on the rise. Obesity brings with it various other health issues such as non alcoholic fatty liver disease, diabetes, arthritis etc. Over the last two decades we have seen that in appropriate cases weight reduction surgeries (bariatrics) have proved to dramatically improve the health of an individual. Endoscopic Sleeve Gastroplasty (ESG), also known as the accordion procedure, works on the same principle as laparoscopic sleeve gastroplasty but without disturbing the integrity of the abdominal cavity.

ESG reduces the size of the stomach using an endoscopic suturing device without the need for surgery. This procedure may be an option for patients who are significantly overweight — a body mass index of 30 or more — and in whom diet and exercise haven't worked.

Who will benefit from this procedure?

ESG is performed to help people lose weight and potentially lower the risk of serious weight-related health problems, including:

Gastroesophageal reflux disease
Heart disease or stroke
High blood pressure
Severe sleep apnea
Type 2 diabetes

What are the advantages of ESG over surgery?

Endoscopic sleeve gastroplasty is less invasive and a more cost effective than other forms of bariatric surgery. However, ESG isn't for everyone who is overweight. There is an initial screening process that will help identify patients who will potentially benefit. The patient must be willing to commit to healthy lifestyle changes, regular medical follow-up and participate in behavioral therapy.

Advantages of endo-surgery over surgery:

Scarless procedure
EMR/ESD/STER offercomplete cure without surgery in early cancers
ESG offers similar results as surgical sleeve gastrectomy
Less blood loss
Cost-effective
Quicker recovery time
Reduced length of hospital stay

In summary:

Over the last decade traditional endocsopy has undergone significant metamorphosis. Now, doctors are able to perform surgical excision without disrupting the natural barrier - the skin. Endosurgery is now a reality. The future for sure arrived.

We have entered a new era in endoscopy. In carefully selected patients endosurgery offers great benefits. However, as the saying goes “with great power comes great responsibility”, so, just as we endoscopists are now equipped with the power to do more, we also have the responsibility to ensure careful selection of appropriate cases so as to continue to deliver high quality of care to our patients.

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