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Per Oral Endoscopic Myotomy (POEM):

POEM is a promising new treatment for achalasia resulting in immediate symptom relief in >90% of cases. September 8, 2008 saw the world’s first clinical case of POEM being performed & perfected successfully by Prof. Dr. Haruhiro Inoue, MD, Showa University Northern Yokohama Hospital, Japan.

It is relatively a new endoscopic procedure used to treat swallowing disorders, most commonly for Achalasia. POEM is a therapeutic endoscopy procedure performed using high-definition upper endoscopes. POEM takes approximately two to three hours, where the patient is expected to stay in the hospital for an average of two days for monitoring and to receive intravenous antibiotics.

Achalasia and other swallowing disorders are usually caused by the esophagus muscles and the lower esophagus sphincter muscles not relaxing, making it hard to swallow and hard for the food to pass into the stomach. Other symptoms besides swallowing issues may be heartburn, weight loss and an overall low quality of life.

Endoscopes are flexible tubes that can be passed through the mouth or rectum. They allow physicians to see and examine the surfaces of the esophagus (food pipe), stomach, intestine and colon without making a large incision elsewhere on the body.

A benefit of having an endoscopic procedure, especially for swallowing disorders, is that there are no incisions in the chest or abdomen and includes a minimal or sometimes no hospital stay post-procedure.

Currently there are only a handful of centers in India offering this less-invasive approach to treating swallowing disorders. The technique originated in Japan by Dr. Haruhiro Inoue and the first case in India was performed by Dr Haruhiro Inoue on a 7 year old patient at our 9th International Advanced Therapeutic Endoscopy and Hands on Workshop in December 2012.

Before the Procedure

Your doctor will discuss with you all the specific preparations that you need to follow. To prepare for the surgery, you will be placed on a liquid diet for two days and not allowed to eat or drink anything for 12 hours before the actual procedure. Fasting keeps your esophagus and stomach clear for the endoscope to pass.

Discuss any medications or allergies with your doctor prior to prep.

The day you arrive at the hospital you will go through a series of examinations prior to being prepped for the procedure.

During Procedure

Once you are all set, you will be given an IV anesthesia and antibiotics. The procedure is performed under general anesthesia and we will insert an arterial line to monitor your pressure during the procedure.

During the procedure an endoscope tube is inserted into your mouth and down your esophagus. An initial incision will be made in the internal lining of the esophagus. This permits entry of the endoscope to within the wall of the esophagus, where the muscle will be exposed. The knife cuts away and loosens the tight muscles on the side of the esophagus, the lower esophagus sphincter and the upper part of the stomach that are causing the swallowing problems.

Once this is complete, endoscopic clips are inserted at the lining of the esophagus to keep the incision at the top closed. The endoscope tube is then removed by coming back up through your mouth.

The procedure relieves the tightness and allows the esophagus to empty like it normally should to pass food down into the stomach

Recovery

You will be admitted in the hospital overnight to make sure there are no complications. You will keep fasting on the night of the procedure.

The following morning and you will be permitted to drink liquids if the test comes back OK. You will advance to a soft diet the following day and will be discharged afterward.

Follow-up care includes meeting with your surgeon as an outpatient seven to 10 days after you have the procedure done. Then you will come in again around the three month mark for another swallow study to make sure your esophagus empties well.

Endoscopic Mucosal Resection (EMR):

Endoscopic Mucosal Resection

Endoscopic mucosal resection was pioneered in Japan for the management of early gastric cancer. It has been also accepted as a therapeutic option for various other gastrointestinal lesions too. The indications have expanded to include treatment of Barrett’s dysplasia, oesophageal squamous dysplasia, small bowel and colorectal adenomas and early cancers. Endoscopic mucosal resection (EMR) also has the advantage of providing an accurate local staging of the disease as compared to ablative therapies such as argon plasma coagulation (APC), photodynamic therapy or radiofrequency ablation (RFA).

This technique needs expertise and adequate training is essential to provide a safe and effective procedure.


Definition

Gastrointestinal endoscopic mucosal resection (EMR) is a procedure to remove cancerous or other abnormal tissues (lesions) confined to the superficial layers (mucosa and submucosa) of the GI tract.

EMR is typically used for removal of lesions smaller than 2 cm or piecemeal removal of larger lesions. Most commonly used techniques can be subdivided as injection-, cap-, and ligation-assisted EMR. Primarily a treatment procedure, EMR is also used to collect tissues for diagnosis. If cancer is present, EMR can help determine if the cancer has invaded tissues beneath the digestive tract lining.

Endoscopic mucosal resection is a less invasive alternative to surgery for removing abnormal tissues from the lining of the digestive tract. These tissues may be:

  • Early-stage cancer
  • Precancerous lesions, which may become cancerous

How you prepare?

Before you have endoscopic mucosal resection, you'll be asked to provide the following information:

  • All prescription medications, over-the-counter drugs and dietary supplements you take — particularly diabetes medications and blood-thinning drugs, including aspirin — and their doses
  • Drug allergies
  • All medical conditions, including heart disease, lung disease, diabetes and blood-clotting disorders

Your doctor may ask you to temporarily stop taking some medications, including those that affect blood clotting or those that interfere with sedatives before the procedure.

Before the procedure

You will be instructed by your doctor about what to do the day before the procedure. These instructions may vary depending on the location of the lesion or lesions being removed. In general, the instructions will likely include:

  • Fasting - You may not be able to eat, drink, and chew gum or smoke after midnight before the procedure.
  • Cleaning the colon - use of a liquid laxative or an over-the-counter enema kit to empty your bowels and clean your colon if the procedure involves the colon.

An informed consent document giving your doctor permission to perform the procedure after the risks and benefits has to be signed by you.

What to expect?

During an endoscopic mucosal resection, you can expect the following:

  • Your role.You'll be asked to change into a gown before the procedure. During the procedure, you'll lie on your side on a cushioned table.
  • Local anesthetic.If the endoscope is inserted through your throat, you may have your throat sprayed or be asked to gargle a solution to numb your throat to make insertion of the endoscope more comfortable.
  • Sedation.You'll be sedated during the procedure. With moderate sedation that causes you to be relaxed and drowsy, you may feel slight movement or pressure during the procedure, but you shouldn't feel pain. Or you may be heavily sedated. Discuss with your gastroenterologist which option is appropriate for you.
  • Monitoring.Nurses or other professionals will monitor your heart rate, blood pressure, blood oxygen level and comfort while the doctor performs the procedure.

During the procedure

There are a few versions of endoscopic mucosal resection. A common approach includes these steps:

  • Inserting the endoscope and guiding the tip to the area of concern
  • Injecting a fluid under a lesion to create a cushion between the lesion & healthy tissue underneath it
  • Lifting the lesion, possibly using gentle suction
  • Cutting the lesion to separate it from surrounding healthy tissue
  • Removing the abnormal tissue from your body
  • Marking the area with ink (tattoo) so that it can be found again with future endoscopic exams

After the procedure

You will be shifted to a recovery room where you will remain until most of the effect of the sedative has worn off. You'll receive written instructions about when you can start eating and drinking and when you can resume normal activities. You'll be advised not to do any of the following activities until the next day:

  • Drive
  • Return to work
  • Make important decisions

Relatively mild side effects may occur within 24 hours after the procedure including:

  • Reactions to the sedative. You may continue to feel drowsiness and may experience nausea and vomiting.
  • Sore throat. If the endoscope was guided down your esophagus, your throat may be sore.
  • Gas or cramps. If air was pumped into your digestive system to make it more accessible, you may have gas, bloating or cramps after the procedure.

Results

Once you are fully awake, a doctor or nurse will provide some information regarding what was found during the procedure, the treatment that was carried out and any further tests that may be required. The polyp is usually retrieved during an EMR procedure and sent to the pathology laboratory for further analysis. It can take up to 7 to 10 days before a result is available. Sometimes, decisions about further treatment can only be made once these results are back.

You'll likely have a follow-up appointment with the gastroenterologist to discuss the outcome of your endoscopic mucosal resection and laboratory tests performed on lesion samples. Questions to ask your doctor include:

  • Were you able to remove all abnormal tissues?
  • What were the results of the laboratory tests? Were any of the tissues cancerous?
  • Do I need to see a cancer specialist (oncologist)?
  • If the tissues are cancerous, will I need additional treatments?
  • How will you monitor my condition?

Follow-up exams

Typically, a follow-up exam is performed three to 12 months after your procedure to be sure the entire lesion was removed. Depending on the findings, your doctor will advise you about further examinations.

An exam will likely include a visual inspection with the use of an endoscope. Your doctor may mark the area of the removed lesion with ink (tattoo) so that when follow-up endoscopy is performed, he or she can be sure the lesion was removed completely.

Risk involved

There is a potential complication associated with all medical procedures.

Risks of the endoscopic mucosal resection include:

  • Bleeding. This most common complication often can be detected and corrected during the procedure.
  • Puncture (perforation). There is a slight risk of a puncture through the wall of the digestive tract, depending on the size and location of the lesion that's removed.
  • Narrowing of the esophagus. Removing a lesion that encircles the esophagus carries some risk of scarring that narrows the esophagus, a condition that may lead to difficulty swallowing and require further treatment.

You'll also receive written instructions about when to call your doctor or get emergency care after the procedure. The following signs or symptoms may indicate a serious complication from endoscopic mucosal resection:

  • Fever
  • Chills
  • Vomiting
  • Black stool
  • Bright red blood in the stool
  • Chest or abdominal pain
  • Shortness of breath
  • Fainting

Endoscopic Submucosal Dissection (ESD):

Endoscopic Submucosal Dissection (ESD)

Endoscopic submucosal dissection (ESD) is an advanced technique of therapeutic endoscopy for superficial gastrointestinal neoplasms. Endoscopic submucosal dissection (ESD) is increasingly being performed for early gastric cancers (EGCs) that are larger than 2 cm and those that are not intestinal-type (IT) cancers. It spares the patient open surgery and with it intra- and post- operative complications. ESD – a minimally invasive intervention has found its application in treatment of early carcinomas, adenomas and lesions in the Gastrointestinal tract. World renowned and leading Gastroenterologists from Japan and Europe are already using this specific intervention in their daily protocol hoping that more and more colleagues will be convinced by its merit and apply it in their practice.

ESD is expanding the limits of endoscopic interventions. It carries a promising future and offers clinical advantages for the treatment of early-stage gastric cancer. The major limitation to the expansion of ESD use is the technical difficulty of the procedure. However, dedicated training and effort has helped Endoscopy Asia develop expertise in this procedure.

Defination

The ESD technique has developed from one of the EMR techniques and is characterized by three steps:

  • (1) injecting fluid into the submucosa to elevate the lesion from the muscle layer,
  • (2) circumferential cutting of the surrounding mucosa of the lesion, and
  • (3) subsequent dissection of the connective tissue of the submucosa beneath the lesion.

Major advantages of this technique in comparison with polypectomy or EMR are -

  • The resected size and shape can be controlled.
  • en bloc resection is possible even in a large neoplasm, and neoplasms with submucosal fibrosis are also resectable. So this technique can be applied to the resection of complex neoplasms such as large neoplasms, ulcerative non-lifting neoplasms, and recurrent neoplasms.

The disadvantages of this technique are -

  • It requires two or more assistants.
  • It is time-consuming.
  • There is a higher risk of bleeding and perforation than EMR.

In Japan, ESD is now gaining acceptance as the standard endoscopic resection technique for stomach neoplasms in an early stage, especially for large or ulcerative neoplasms as it provides excellent result of en-bloc resection compared to endoscopic mucosal resection (EMR). Recently, Endoscopy Asia had applied the ESD technique to esophageal or colorectal neoplasms in some cases and has successfully obtained favorable outcomes compared to EMR.

How you prepare?

Before you have endoscopic sub-mucosal dissection, you'll be asked about:

  • All prescription medications, over-the-counter drugs and dietary supplements you take — particularly diabetes medications and blood-thinning drugs, including aspirin — and their doses
  • Drug allergies
  • All medical conditions, including heart disease, lung disease, diabetes and blood-clotting disorders

You might be asked to temporarily stop taking some medications, including those that affect blood clotting or those that interfere with sedatives before the procedure.

Before the procedure

Our doctor will guide you on what to do the day before the procedure. These instructions may vary depending on the location of the lesion or lesions being removed. In general, the instructions will likely include:

  • Fasting - You may not be able to eat, drink, and chew gum or smoke after midnight before the procedure.
  • Cleaning the colon - use of a liquid laxative or an over-the-counter enema kit to empty your bowels and clean your colon if the procedure involves the colon.

You will be asked to read and sign an informed consent document which gives your doctor permission to perform the procedure.

What to expect?

During an endoscopic sub-mucosal dissection, you can expect the following:

  • Your role You'll be asked to change into a gown before the procedure. During the procedure, you'll lie on your side on a cushioned table.
  • Local anesthetic If the endoscope is inserted through your throat, you may have your throat sprayed or be asked to gargle a solution to numb your throat to make insertion of the endoscope more comfortable.
  • Sedation During the procedure you will be given moderate sedation that causes you to be relaxed and drowsy, you may feel slight movement or pressure during the procedure, but you shouldn't feel pain. Or you may be heavily sedated. Discuss with your gastroenterologist which option is appropriate for you.
  • Monitoring Nursing staff will monitor your heart rate, blood pressure, blood oxygen level and comfort while the doctor performs the procedure.

During the procedure

There are a few versions of endoscopic sub-mucosal resection. A common approach includes these steps:

Step 1: Marking

Before elevation, the lateral safety margin is marked with coagulation points at smallest possible intervals with the lesion demonstrating a peripheral zone of 5-7 mm. The mode is suitable for this procedure.

Step 2: Elevation

The HybridKnife is positioned on the mucosa with a slight amount of pressure and an application angle of approx. 20°. The waterjet penetrates the soft mucosa and accumulates in the collagenous fibers of the submucosa, which becomes bloated in a pillow-like fashion.

The “cushioned” submucosa forms a safety margin to the muscularis, thus minimizing the risk of perforation during initial and circular incision of the lesion when the ESD method is used. The submucosal cushion also provides protection against the thermal damage of the muscularis. Since the blood vessels are compressed by the fluid cushion, risk of bleeding is minimized. The operation can be performed with little bleeding and a good view of the target area.

Step 3: Incision/dissection

Circular mode of incision is made throughout the periphery of the neoplasm.

Step 4: Coagulation

Blood vessels and leakages are coagulated during and after resection. Hemostasis is enhanced by compressive fluid cushion

After the procedure

You will be shifted to a recovery room where you will remain until most of the effect of the sedative has worn off. You'll receive written instructions about when you can start eating and drinking and when you can resume normal activities. You'll be advised not to do any of the following activities until the next day:

  • Drive
  • Return to work
  • Make important decisions

Patients are usually hospitalized after an ESD is performed. After ESD, eating is usually started on the next or 2 days after ESD if there is no complication, and the patient may be discharged within few days. Antacids are usually administered to gastric and esophageal ESD patients to relieve pain, prevent postoperative bleeding and promote ulcer healing. Ulcers after ESD are reported to heal within 6 to 8 wk in the esophagus, stomach and colorectum.

Relatively mild side effects may occur within 24 hours after the procedure including:

  • Reactions to the sedative You may continue to feel drowsiness and may experience nausea and vomiting.
  • Sore throat If the endoscope was guided down your esophagus, your throat may be sore.
  • Gas or cramps If air was pumped into your digestive system to make it more accessible, you may have gas, bloating or cramps after the procedure.

Results

A precise pathological evaluation of the resected specimen is essential, and an en bloc resection of the lesion is desirable in this respect. After removal, the specimen should be oriented immediately before it is immersed in formalin. The submucosal side of the specimen is faced to the plate. The depth of invasion is then evaluated microscopically along with the degree of differentiation and lymphovascular infiltration, if any. In result of thorough pathological assessment, if the lesion is resected en bloc with negative margins of neoplasm, the treatment is judged as curative resection.

You'll likely have a follow-up appointment with the gastroenterologist to discuss the outcome of your endoscopic mucosal resection and laboratory tests performed on lesion samples. Questions to ask your doctor include:

  • Were you able to remove all abnormal tissues?
  • What were the results of the laboratory tests? Were any of the tissues cancerous?
  • Do I need to see a cancer specialist (oncologist)?
  • If the tissues are cancerous, will I need additional treatments?
  • How will you monitor my condition?

Follow-up exams

Typically, a follow-up exam is performed three to 12 months after your procedure to be sure the entire lesion was removed. Depending on the findings, your doctor will advise you about further examinations.

An exam will likely include a visual inspection with the use of an endoscope. Your doctor may mark the area of the removed lesion with ink (tattoo) so that when follow-up endoscopy is performed, he or she can be sure the lesion was removed completely.

Risk involved

There is a potential complication associated with all medical procedures.

Risks of the endoscopic mucosal resection include:

  • Bleeding This most common complication often can be detected and corrected during the procedure.
  • Puncture (perforation) There is a slight risk of a puncture through the wall of the digestive tract, depending on the size and location of the lesion that's removed.
  • Stricture Stricture after ESD may occur in esophageal ESD when the ESD ulcer is larger than two-third of circumference of the esophageal lumen, or in gastric ESD when the ESD ulcer involves more than three quarter of the pylorus or pre-pylorus area.

You'll also receive written instructions about when to call your doctor or get emergency care after the procedure. The following signs or symptoms may indicate a serious complication from endoscopic mucosal resection:

  • Fever
  • Chills
  • Vomiting
  • Black stool
  • Bright red blood in the stool
  • Chest or abdominal pain
  • Shortness of breath
  • Fainting