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Endosurgical Management of Luminal Disease

Andrew T. Pellecchia, MDDirector of Advanced Endoscopy

MVHS/St. Luke's Hospital

Etymology• Mucosa, -ae. Latin first declension feminine

of Mucosus.

• Slimy

• Polyp. Greek (Polypos), Latin (Polypus) second declension masculine

• Many (poly) feet (*ped)

• Cuttlefish, octopus

The 2-3mm Endosurgical Field, an Anatomy Primer

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Volumetric Laser Endomicroscopy

Opening Case Study, A Common AES Referral

42 y.o. man with a h/o long segment Barrett’s esophagus who was referred for radiofrequency ablation

Prior biopsies showed dysplasia

Non-smoker

No family history

Personal history of obesity

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EGD

EGD with NBI and Near Focus

Endoscopy Findings

• Long segment Barrett’s extending from 37cm to 33cm.

• Worrisome 25mm x 20mm raised patch at 34cm with the distal portion of the lesion residing just proximal to a bend in the esophageal lumen.

• Absolute contraindication to RFA

• Biopsies taken carefully

• HGD with invasive adenocarcinoma not ruled out

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Endosurgical Plan Pre-operative Testing:

High Definition EGD with NBI and Near Focus imaging and biopsies

CBC, CMP, INR Normal

CT c/a/p with contrast Unremarkable

EUS to evaluate for T and N stage with on-site pathological evaluation of LN samples No contra-indication to resection

Endosurgical Plan, Continued Selection of Surgical Technique

Endoscopic Mucosal Resection (EMR)

Endoscopic Submucosal Dissection (ESD)

Note: There is NO ROLE for esophagectomy in superficial neoplasms of the esophagus in the absence of contra-indications to endosurgicalmanagement.

Endosurgical Techniques

Endoscopic Mucosal Resection (EMR)

Technically easier

Lower Risk

Smaller Lesions

Premalignant Lesions

Location in Bowel Colon, Duodenum

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Colon Polyp EMR

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Endosurgical Techniques

Endoscopic Submucosal Dissection (ESD)

Extremely difficult to master

Difficult procedure even after competence reached

Higher risk for complication

En bloc resection/surgical R0 resection

Vastly superior results for many lesions Preferred approach for all but the smallest

malignancies

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Further Considerations

ESD learning curve

No billing code for ESD

Should NEVER prevent appropriate use of this technique

Mark Surgical Margins

Lift and Cut

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Dissect Submucosa and Vessels and Fibrosis

ESD Procedure Video

Final Resection Base

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Large Mucosal Defect Management

No closure

Eg. Esophagus with concern for lumen compromise/stricture

Endoclip closure

Douglas Rex, MD recent study on colon polypectomy closure showed decreased post-polypectomy bleeding with ppx clipping

Endoclip/Endoloop closure

Used in China for defect and perforation closure

Endosuturing closure

Colon Polyp EMR, APC, Clip

Overstitch Endosuturing Device

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Spin-Off Benefits of Mastering Endoscopic Suturing

Suture anchoring of luminal stents

Dramatically reduces risk of migration

Endoscopic closure of fistula

Endoscopic closure of perforations

Within short time interval, hours

Stable patients

Location and degree of perforation

Cleanliness of site

Necessary for FTER, STER, POEM, POP, etc

ESD Defect Closure Case Study

• 60 y.o. woman of Korean descent with raised gastric adenoma on the incisura in a background of gastric intestinal metaplasia

• Non-smoker

• Family history of fatal gastric cancer in brother, age 40

Gastric Lesion

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ESD

Endosurgical Closure

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Final Pathology

• Final pathology revealed adenoma with HGD, negative surgical margins.

• Subsequent endoscopic surveillance with gastric mapping revealed gastric intestinal metaplasia throughout all areas of the stomach except for the fundus.

ESD with Submucosal Fibrosis, Case Study

• Tattoo ink seen under polyp.• Leads to massive fibrosis of

submucosa.• Successful attempt to avoid

surgery.

Sessile Serrated Adenoma

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Fistula Closure, Case Study

• 31 y.o. man with chronic gastrocutaneous fistula from PEG tube.

• Procedure performed before availability of endoscopic suturing.

• Endoclip/Endoloop purse-string method utilized.

• Completely air and water tight for > 1 month

• Ultimately breaks down and fails

Gastrocutaneous Fistula

Clipping Loop Around Fistula

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Prior to Loop Closure

After Purse String Cinch

Attempt at Salvage Clipping

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Suture Fixation of Duodenal Stent, Case Study

• 89 y.o. man with adenocarcinoma of the distal bile duct/major papilla

• Obstructive jaundice

• Gastric outlet obstruction secondary to direct invasion of the duodenal bulb and sweep

Fully Covered Metal Biliary Stent

D1 Duodenal Obstruction

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Trans-pyloric View of Obstruction

Duodenal Stent Deployment

Suture Anchor to Antrum

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Esophageal Stent Fixation

• Dysphagia from esophageal adenoca

• EUS staging, dilation, stent deployment, and stent fixation

Endoscopic Weight Loss

De novo endoscopic sleeve gastroplasty

Post Surgical Roux-en-Y gastrojejunostomy stoma reduction

Stoma Reduction

53 y.o. woman 5 years s/p Roux-en-Y gastric bypass with initial weight loss followed by gradual weight gain.

BMI: 37

Pre-procedure Weight: 196

EGD reveals G-J opening >20mm

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Gastrojejunostomy

Mucosal Ablation Prior to Suture

Post-Suture Sizing with 8mm Balloon

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Post-Suturing View

Gastrojejunostomy After Reduction

Before and After

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Stoma Reduction after Roux

First case performed at MVHS this year

Starting weight: #196

Weight 3 months after stoma reduction: #168

>13% weight loss

Patient is 2 pounds shy of her original post-Roux lowest weight. Exercise will yield further weight reduction