Endoscopic resections for cancerous and precancerous lesions (polyps)

Advanced endoscopic (surgical) resections are a set of procedures that focus on the treatment of common diseases of the gastrointestinal tract, which include polyp resection, excision and even exit from the gastrointestinal tract.
Following improvements in endoscopic instrumentation and the development of innovative techniques, endoscopic treatment that allows a more accurate diagnosis of the disease, leads to excellent long-term results and is a cheaper, higher quality and safer substitute compared to traditional surgery.

Advanced endoscopy, which is more complex than regular endoscopy, requires specific experience and learning and is therefore performed in the hospital by a team trained in this type of operations.

Advanced endoscopic resections are divided in two main directions:

1. Treatment of precancerous/cancerous lesions of the gastrointestinal mucosa
2. Treatment of tumors of the submucous membrane in the gastrointestinal tract

Treatments for precancerous/cancerous lesions (including polyps) in the gastrointestinal tract.

Usually the initial diagnosis of a precancerous / cancerous lesion of the mucosa of the gastrointestinal tract will be made outside the hospital during an endoscopic examination. After preliminary processing of all data the doctor directs the further treatment to the hospital. We receive the referrals, go through the data, invite the patient to action after giving detailed explanations.

Careful endoscopic evaluation before resection of both the upper and lower gastrointestinal tracts is necessary for the correct determination of therapeutic strategy and the choice of the most appropriate endoscopic or surgical technique. We perform this assessment before the operation using the most advanced optical technologies, which allow us to estimate the degree of differentiation of the lesion and the risk of the presence of invasive cancer with an accuracy of up to 90%.

AFTER EVALUATION, FURTHER TREATMENT OF THE LESION WILL BE CARRIED OUT BY ONE OF THE THREE POSSIBLE OPTIONS: ESD, EMR OR SURGERY.

ENDOSCOPIC SUBMUCOSAL DISSECTION (ESD)

ESD IS AN "ENDOSCOPIC PROGENITOR OF THE SUBMUCOUS MEMBRANES"

AN ADVANCED ENDOSCOPIC METHOD (WHICH WAS DEVELOPED IN JAPAN) FOR EXCISION OF LESIONS FROM THE MUCOSA OF THE GASTROINTESTINAL TRACT. THIS ALLOWS DEEP ENDOSCOPIC RESECTION OF LARGE POLYPS SUSPECTED OF BEING MALIGNANT AND TUMORS IN EARLY STAGES. ACCORDING TO A PRELIMINARY ENDOSCOPIC DIAGNOSIS WITHOUT THE NEED FOR SURGERY OR ADDITIONAL TREATMENT. ESD THAT ALLOWS COMPLETE RESECTION OF SUPERFICIAL TUMORS IN THE GASTROINTESTINAL TRACT, WITHOUT LIMITING THE SIZE OF THE LESION.

Such operations are performed by gastroenterologists experienced in invasive endoscopy, having undergone only appropriate training.

ENDOSCOPIC MUCOSAL RESECTION (EMR)

EMR IS "ENDOSCOPIC RESECTION OF THE MUCOSA"  

THE MAIN USE OF THIS TECHNIQUE IS IN THE LARGE AND THIN INTESTINE FOR EXCISION OF POLYPS LARGER THAN 20 MM. EMR METHOD IT IS POSSIBLE TO REMOVE POLYPS OF ANY SIZE, WHICH DO NOT HAVE CHARACTERISTICS THAT SUSPECT MALIGNANT INVOLVEMENT OF THE POLYP.

IN ADDITION, IN SOME CASES THIS TECHNIQUE CAN BE USED TO TREAT ESOPHAGEAL LESIONS SUCH AS THE BARRETTS MUCOSA AND IN ADDITION TO SMALL LESIONS IN THE STOMACH.

Resection is performed by injecting fluid into the submucosa under the tumor and separating a polyp/lesion from the mucosa below it. The mucosa is cut in pieces by a loop-shaped knife until the tumor is completely removed.

Risks:

THE MAIN RISKS OF BOTH METHODS (EMR, ESD) BLEEDING OR INJURY TO THE INTESTINAL / STOMACH / ESOPHAGUS WALL. THE SIZE OF THE RISK DEPENDS ON THE LOCATION OF THE LESION IN THE GASTROINTESTINAL TRACT, ITS SIZE AND METHOD OF TREATMENT. IN THE VAST MAJORITY OF COMPLICATIONS, IT CAN BE TREATED ENDOSCOPICALLY WITHOUT THE NEED FOR SURGERY OR ADDITIONAL TREATMENT WHILE MAINTAINING THE EFFECTIVENESS OF THE TREATMENT.

In addition to the risks at the time of operation there is a risk of bleeding and the formation of a scar with stenosis (mainly esophagus). The complications are usually not severe and can be treated endoscopically.

Follow up:

An integral part of the treatment is the follow-up that includes endoscopy for control. Regrowth of the lesion can reach up to about 20% in some cases. However, these growths are small and are effectively handled during the audit with excellent long-term results.

Treatment of tumors of the submucous membrane in the gastrointestinal tract

Common tumors are of the type:

1.NEUROENDOCRINETUMOR (NET)

2. GASTROINTESTINAL STROMAL TUMOR (GIST)

3. OTHER (LIOMYOMA, LIPOMA, TUMOR CELL GRANULAR).

EACH PATIENT MUST UNDERGO A PRELIMINARY DIAGNOSIS AND EVALUATION BEFORE DECIDING ON ENDOSCOPIC RESECTION, WHICH INCLUDES AN ENDOSCOPIC ULTRASOUND (EUS) WITH EITHER A BIOPSY AND AN IMAGING TEST SUCH AS A CT (COMPUTER TOMOGRAPHY).

TUMORS THAT DO NOT PENETRATE THE MUSCULAR LAYER CAN BE EXCISED BY EMR OR ESD.

Tumors involving the mucosal layer can be excised by endoscopic methods such as

1.Submucosal tunneling endoscopic resection (STER)

STER IS AN ORAL SURGERY TO REMOVE A TUMOR OF A SUBMUCOSA IN THE UPPER GASTROINTESTINAL TRACT (ESOPHAGUS/STOMACH). THE METHOD IS SUITABLE FOR EXCISION OF TUMORS WITH A DIAMETER OF 2-4 CM.

After an initial cut, the endoscope is inserted into the canal between the mucosa and the wall muscles of the esophagus or stomach. The canal is built until the tumor itself and then it is separated from the wall while preserving the mucosa that surrounds the tumor. At the end of the operation, the initial incision closes with clips.

THE OPERATION IS PERFORMED WITHOUT INCISIONS IN THE ABDOMINAL WALL AND WITHOUT SEPARATION OF TISSUES IN ORDER NOT TO REVEAL THE LOCATION OF THE TUMOR. ONE OF THE ADVANTAGES OF THE STER METHOD IS THAT THERE IS NO DAMAGE TO THE MUCOSA AND THEREFORE THERE IS NO RISK OF CONTRACTIONS.  

EFTR IS AN ORAL/RECTAL SURGERY TO REMOVE A TUMOR OF A SUBMUCOSA IN THE UPPER/LOWER GASTROINTESTINAL TRACT WITH A COMPLETE RESECTION OF THE GASTRIC/ESOPHAGUS/INTESTINAL WALL THAT INCLUDES THE TUMOR. AT THE END OF THE OPERATION, THE DEFECT IN THE WALL CAN BE CLOSED BY SPECIAL CLIPS OR AN ENDOSCOPIC SEWING DEVICE.

As with other endoscopic treatments, the main risks involve complications of bleeding or perforation up to about 15%, but here, too, most of them can be treated endoscopically. There is also a concern of a breakout of the capsule of the tumor and its dispersion in the abdominal cavity.

Follow up:

If a tumor is excised in its entirety, there is no need for close endoscopic follow-up after the operation.

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