ENDOSCOPIC SURGERY
ADVANCED ENDOSCOPIC DIAGNOSTIC AND THERAPEUTIC METHODS
Cutting edge advancements in fiberoptic endoscopy have enabled early diagnosis and accurate staging for gastrointestinal diseases. Developments in minimally invasive endoscopic diagnostic and therapeutic methods for early stage cancers within the last 20 years and the use of third-space endoscopy (submucosal endoscopy) for the past decade allow most of gastrointestinal diseases (achalasia, esophageal diverticulum, gastric and intestinal polyps etc.) to be treated through endoscopic methods (such diseases could previously be treated only with open surgery). Thanks to these advancements, minimally invasive advanced endoscopic procedures are preferred rather than open surgical interventions.
These globally accepted procedures and practices requiring special technical competency can be performed by an experienced team at our Advanced Endoscopy Center. Main advantages of minimally invasive advanced endoscopic treatment methods with proven efficiency and safety are as follows:
Such procedures do not cause loss of organ, shorten the hospitalization period, are associated with very minimal side effects and provide rapid recovery.
In addition to these methods employed at our center, novel methods have been developed swiftly. Our “Advanced Endoscopy Center”, which is one of globally accepted excellence centers, keeps on developing and growing with each passing day.
The main advanced endoscopic diagnostic and therapeutic methods applied at our Advanced Endoscopy Center are as follows:
1. Chromoendoscopy and Endoscopic Ultrasound (EUS);
Chromoendoscopy is an endoscopic examination method that is applied to evaluate esophageal, gastric, colonic and duodenal premalignant and early stage malignant lesions and to investigate invasion (spread of the disease within the tissues) before endoscopic submucosal dissection (ESD), endoscopic mucosal resection (EMR), endoscopic full thickness resection (EFTR) and laparoscopic endoscopic combined resection (LECS). During the procedure, structural features of the lesions are examined through a proper endoscope (NBI, near focus, magnification etc.). Later, the lesion field is dyed with Lugol’s solution or Indigo carmine and margins and structures of the lesion are analyzed.
If the lesion is subepithelial (gastrointestinal stromal tumor, leiomyoma), EUS is carried out to determine the origin of the lesion or investigate depth of invasion of the malignant lesion. This procedure requires more time and experience compared to conventional endoscopy and colonoscopy. The procedure lasts for 15 to 30 minutes depending on experience. The procedure is carried out under minimal anesthesia at endoscopy unit. If resection will be performed afterwards, general anesthesia can be induced or the procedure can be performed directly under general anesthesia.
2.Endoscopic Mucosal Resection (EMR)
It is an advanced endoscopic treatment method applied for esophageal, gastric, duodenal and colonic premalignant /early stage malignant lesions. There are various types available (Band EMR, precut EMR etc.). The most appropriate type is decided considering the size of the lesion (<3 cm) or characteristics of the lesion (neuroendocrine tumor, granular cell tumor etc.)
The procedure is performed under sedoanalgesia at Advanced Endoscopy Unit. Hospitalization is generally not necessary after the procedure is completed.
3. Endoscopic Submucosal Dissection (ESD);
It is a minimally invasive treatment method through which esophageal, gastric, duodenal and colonic premalignant (polyp) and early stage malignant lesions are removed with non-surgical approach using the special laser beams and/or electric knives passing through the endoscope. Prior to the procedure, chromoendoscopy and EUS are performed to determine the margins of the diseased area and stage the condition. Additional radiologic imaging tests (regional tomography and/or MRI) are performed with a multidisciplinary approach depending on the size and location of the lesion. ESD is planned, if it is possible to remove the lesion with endoscopic method. ESD is performed under anesthesia at advanced endoscopy unit. The duration of the procedure varies depending on the size and location of the lesion. ESD procedures have been successfully performed for every part of the gastrointestinal system at our Advanced Endoscopy Unit since 2013. Our team shares their knowledge and experience during local and international trainings held at our RMK-AIMES laboratory.
Based on the application areas;
3.1 Esophageal ESD: The procedure is performed under general anesthesia and supervision of anesthesiologist at well-equipped advanced endoscopy unit. The duration of the procedure varies depending on the endoscopist’s experience (generally 1 to 3 hours). After the procedure is completed, the patient is monitored at inpatient clinic for 1 to 2 days.
3.2 Gastric ESD: The procedure is performed under sedo-anesthesia or general anesthesia and supervision of anesthesiologist at well-equipped advanced endoscopy unit. The duration of the procedure varies depending on the endoscopist’s experience (generally 30 minutes to 2 hours). After the procedure is completed, the patient is monitored at inpatient clinic for 1 to 2 days.
3.3 Duodenal ESD: The procedure is performed under general anesthesia and supervision of anesthesiologist at well-equipped advanced endoscopy unit. The duration of the procedure varies depending on the endoscopist’s experience (generally 2 to 4 hours). After the procedure is completed, the patient is monitored at inpatient clinic for 1 to 3 days.
3.4.Colonic-Rectal ESD and Per Anal Endoscopic Myectomy (PAEM): The procedure is performed under sedoanesthesia, spinal anesthesia or general anesthesia and supervision of anesthesiologist at well-equipped advanced endoscopy unit. The duration of the procedure varies depending on the endoscopist’s experience and the size of the lesion (generally 30 minutes to 3 hours). After the procedure is completed, the patient is monitored at inpatient clinic for 1 to 2 days.
4. Per-Oral Endoscopic Myotomy (POEM, E-POEM)
Achalasia is a digestive system disease caused by the loss or failure of the nerve endings that are responsible for relaxation of muscles in esophagus, resulting in esophageal motility disorder and difficulty swallowing. One of the widely accepted treatment methods for the condition is POEM, which is an advanced endoscopic treatment method developed in Japan in 2010. In our country, the procedure was first performed by our team in 2014. Our unit is one of the centers where this procedure is routinely performed in the world. Before the procedure, high-resolution manometry (HRM) is used to identify the type of achalasia and radiologic imaging study is made to determine the characteristics of the esophagus.
The procedure is performed under general anesthesia and supervision of anesthesiologist at well-equipped advanced endoscopy unit. The procedure lasts for 20 to 75 minutes. The patient is hospitalized one day before the procedure and monitored at inpatient clinic for 1 to 3 days after the procedure.
5. Gastric Per-Oral Endoscopic Myotomy-Endoscopic Pyloromyotomy (G-POEM/POP)
Gastroparesis is a rare motility disorder characterized by gastric emptying disorder secondary to diabetes, surgery and connective tissue diseases. One of the accepted non-surgical endoscopic treatment methods for this condition is G-POEM/POP.
The procedure is performed under general anesthesia and supervision of anesthesiologist at well-equipped advanced endoscopy unit. The procedure lasts for 20 to 75 minutes. The patient is hospitalized one day before the procedure and monitored at inpatient clinic for 1 to 2 days after the procedure.
6.Submucosal Endoscopic Tunneling Resection (STER/POET)
It is a minimally invasive advanced endoscopic treatment method applied in non-surgical treatment of subepithelial lesions of the esophagus and stomach (gastrointestinal stromal tumor-GIST, leiomyoma, neuroendocrine tumor etc.). Before the procedure, EUS and additional radiologic imaging studies (multi-slice computed tomography) are performed to determine the origin of the lesion. The size of the lesion and its relation to neighboring areas are identified.
The procedure is performed under general anesthesia and supervision of anesthesiologist at well-equipped advanced endoscopy unit. The procedure lasts for 30 to 120 minutes. After the procedure is completed, the patient is monitored at inpatient clinic for 1 to 3 days.
7. Endoscopic Full-Thickness Resection (EFTR)
It is a non-surgical advanced endoscopic treatment method applied for esophageal, gastric, duodenal and colonic subepithelial lesions. Before the procedure, EUS and additional radiologic imaging studies (multi-slice computed tomography) are performed to determine the origin of the lesion. The size of the lesion and its relation to neighboring areas are identified.
The procedure can be performed under general anesthesia at the operating theatre or at endoscopy unit if surgical conditions are met. The procedure lasts for 30 to 120 minutes. After the procedure is completed, the patient is monitored at inpatient clinic for 2 to 3 days.
8.Laparoscopic Endoscopic Surgery (LECS)
It is a treatment method applied for subepithelial lesions of the stomach and colon. If subepithelial lesions are large (>5 cm), such that they cannot be removed from the esophagus or anus with endoscopic technique, LECS is performed as a minimally invasive endoscopic and laparoscopic treatment to minimize organ loss. Before the procedure, EUS and additional radiologic tests are done to stage the condition.
The procedure is performed under general anesthesia at the operating theatre by general surgery team trained on the use of laparoscopic-robotic methods. The procedure lasts for 120 to 180 minutes. After the procedure is completed, the patient is monitored at inpatient clinic for 1 to 4 days.
9. Zenker’s Diverticulum / Esophageal Diverticula; Endoscopic Septomyotomy (D-POEM)
Zenker’s diverticulum is a rare anatomical disorder that develops in the upper end and corpus of the esophagus, resulting in difficulty swallowing and weight loss. There are various types available (D-POEM, Z-POEM, STESD, Classic etc.) The most appropriate treatment method is decided by considering radiologic and endoscopic test results and the size and location of the diverticulum at our advanced endoscopy unit.
The procedure is performed under sedoanesthesia or general anesthesia at advanced endoscopy unit. Generally, 1 to 2 days of hospital stay is recommended after the procedure.
10. Endoscopic Sleeve Gastroplasty (Overstitch Gastroplasty);
It is a non-surgical advanced endoscopic gastric reduction method applied with FDA-approved endoscopic suture system, which has been used in treatment of obesity for the past decade in the U.S.A. The patient is assessed at our advanced endoscopy unit and surgery clinic. Then, the procedure is performed under general anesthesia at advanced endoscopy unit, if indicated. Generally, staying at the hospital overnight is recommended after the procedure.
11. Endoscopic Suturing Procedures (Stent fixation, closure of ESD and Closure of EFTR Field and Closure of Fistula)
Non-surgical advanced endoscopic procedure with FDA-approved endoscopic suturing system is performed to:
- Prevent late postoperative bleeding or late perforation and shorten hospitalization period in treatment of early stage GI tumors and polyps,
- Prevent stent dislocation,
- Close the incision site in G-POEM/POP.
- Close the resection site in endoscopic full thickness resection.
Endoscopic suturing procedure is performed immediately after other procedures or during control endoscopy at advanced endoscopy unit.
12. Spiral Enteroscopy
It is one of the most advanced endoscopic procedures applied in diagnosis and management of small intestine cancer. This method is applied at only two centers in the Europe and only by our team in our country. It is a minimally invasive diagnostic and therapeutic method associated with higher success rate and shorter duration comparing to other enteroscopy methods performed under general anesthesia. The procedure is performed under general anesthesia at advanced endoscopy unit and lasts for 45 to 90 minutes.
13. Anti-reflux Mucosectomy-Treatment of Reflux
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Anti-reflux Mucosectomy is an advanced endoscopic treatment method developed in Japan, which has been used for the past 5 years for the reflux patients without hiatal hernia. The procedure is performed under general anesthesia and completed within 1 to 2 hours. Hospitalization for 1 day is recommended after the procedure.
- Trans Oral Fundoplication is an advanced endoscopic treatment method developed in the U.S.A and performed using FDA-approved TIF-2 consumables for the patients with hiatal hernia measuring up to 2 cm in diameter. The procedure is performed under general anesthesia and completed within 1 to 2 hours. 1-day hospital stay is recommended after the procedure.
- Per-Oral Endoscopic Fundoplication (POEF): It is an advanced endoscopic treatment method developed in Japan and applied especially for the patients with achalasia associated with reflux. The procedure is performed under general anesthesia and completed within 1 to 2 hours. Hospitalization for 1 day is recommended after the procedure.
- Stretta Procedure; it is a treatment method, which is commonly applied in the Europe and U.S.A. and used with FDA-approved consumables for the patients without hiatal hernia. The procedure can be performed under sedoanalgesia within 15-30 minutes and hospital stay is not required.
14. Electroincision-Laser Dilatation Procedures
These are endoscopic treatment methods applied for ingestion of caustic substance and postoperative stenoses at the anastomosis line that can be combined with multiple interventions. Electroincision method is used especially for treatment of postoperative stenoses at the anastomosis lines. It is a rarely used treatment method that allows the excision of the fibrotic tissue as well. The procedure is performed under sedoanesthesia or general anesthesia at advanced endoscopy unit.
In conclusion, all these procedures performed at our advanced endoscopy unit are non-surgical minimally invasive endoscopic treatment methods with proven efficiency and safety that do not cause organ loss, shorten the hospitalization period and are associated with very minimal side effects and rapid recovery. In addition to these procedures, novel procedures have been developed with each passing day. Our advanced endoscopy center keeps developing and growing as one of the globally accepted excellence centers.