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Focus On Flexible Gastrointestinal (GI) Endoscopy!

Epublication, Feb 2016;16(02). URL: http://websurg.com/doi/fc01en8
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LIVE INTERACTIVE SURGERY: Endoscopic Submucosal Dissection (ESD) for colonic polyp
Colorectal polyps are the most common type of polyps. Early resection before the polyp undergoes malignant transformation is key to long-term survival and to a favorable prognosis.
Endoscopic submucosal dissection (ESD) has been developed based on endoscopic mucosal resection (EMR) techniques. ESD can be used to resect lesions regardless of size, location, and fibrosis.

Indications for ESD:
- colorectal tumors when EMR is not feasible;
- tumors >20mm in size;
- lateral spreading tumors (non-granular) type;
- lateral spreading tumors (granular type) with a nodule;
- residual and recurrent tumors.

Technique:
- to accurately define the margins;
- to mark the borders;
- to perform a circumferential incision;
- to perform a submucosal dissection.

Complications:
- perforations – 2.4% in colonic ESD;
- bleeding – may be immediate or delayed, occurring after the procedure.
The overall rate of complications is 1.5%.

Endoscopic ultrasound (EUS):
The use of high-frequency EUS is useful to determine the depth of invasion of colorectal lesions. According to some studies, the efficacy of EUS is found to be superior to chromoendoscopy in determining the depth of the tumor.
N Fukami
Surgical intervention
2 years ago
733 views
32 likes
0 comments
32:29
LIVE INTERACTIVE SURGERY: Endoscopic Submucosal Dissection (ESD) for colonic polyp
Colorectal polyps are the most common type of polyps. Early resection before the polyp undergoes malignant transformation is key to long-term survival and to a favorable prognosis.
Endoscopic submucosal dissection (ESD) has been developed based on endoscopic mucosal resection (EMR) techniques. ESD can be used to resect lesions regardless of size, location, and fibrosis.

Indications for ESD:
- colorectal tumors when EMR is not feasible;
- tumors >20mm in size;
- lateral spreading tumors (non-granular) type;
- lateral spreading tumors (granular type) with a nodule;
- residual and recurrent tumors.

Technique:
- to accurately define the margins;
- to mark the borders;
- to perform a circumferential incision;
- to perform a submucosal dissection.

Complications:
- perforations – 2.4% in colonic ESD;
- bleeding – may be immediate or delayed, occurring after the procedure.
The overall rate of complications is 1.5%.

Endoscopic ultrasound (EUS):
The use of high-frequency EUS is useful to determine the depth of invasion of colorectal lesions. According to some studies, the efficacy of EUS is found to be superior to chromoendoscopy in determining the depth of the tumor.
LIVE INTERACTIVE SURGERY: Colonoscopy and resection of large pedunculated sigmoid colon polyp
An intestinal polyp is a mass of tissue, which arises from the bowel wall and protrudes into the lumen. Polyps may be sessile or pedunculated. The incidence of polyps ranges from 7 to 50%. Polyps are most commonly found in the rectum and sigmoid colon and decrease in frequency towards the caecum.
Symptoms and signs:
Polyps are usually asymptomatic. The most frequent complaint is rectal bleeding, which is usually occult. Abdominal pain and obstruction occur with large polyps. The main concern with polyps is the risk of malignant transformation.
Complications of polypectomy: Common complications following polypectomy are bleeding and infection. The risk of bleeding ranges from 0.2 to 1.2%. When patients are on blood thinners, the risk of bleeding increases to 6.8%.
Advantages and disadvantages of use of prophylactic clips:
Clips can be applied during the procedure itself. They are easy to deploy. No scarring can be observed.
Disadvantages:
They are expensive, and present a risk of perforation and further bleeding.
R Dumas, S Leblanc
Surgical intervention
2 years ago
1031 views
39 likes
0 comments
11:52
LIVE INTERACTIVE SURGERY: Colonoscopy and resection of large pedunculated sigmoid colon polyp
An intestinal polyp is a mass of tissue, which arises from the bowel wall and protrudes into the lumen. Polyps may be sessile or pedunculated. The incidence of polyps ranges from 7 to 50%. Polyps are most commonly found in the rectum and sigmoid colon and decrease in frequency towards the caecum.
Symptoms and signs:
Polyps are usually asymptomatic. The most frequent complaint is rectal bleeding, which is usually occult. Abdominal pain and obstruction occur with large polyps. The main concern with polyps is the risk of malignant transformation.
Complications of polypectomy: Common complications following polypectomy are bleeding and infection. The risk of bleeding ranges from 0.2 to 1.2%. When patients are on blood thinners, the risk of bleeding increases to 6.8%.
Advantages and disadvantages of use of prophylactic clips:
Clips can be applied during the procedure itself. They are easy to deploy. No scarring can be observed.
Disadvantages:
They are expensive, and present a risk of perforation and further bleeding.
Staging before endoscopic resection: EMR and ESD
Pre-procedural planning before any endoscopic resection requires the assessment of the lesion. The main criteria which need to be assessed are the following:
- depth of invasion of the lesion;
- lymph node metastasis;
- lateral spread of the tumor;
- pit pattern.
Routine endoscopy is used to assess tumor size. Tumors can be staged with the use of many classifications, and notably the Paris classification.
High-frequency (≥20MHz) endoscopic ultrasonography (EUS) produces an image of the mucosal wall comprising nine separate layers differentiated by their echogenicity. Careful examination of the depth of lesion penetration into the mucosal and submucosal layers is used to determine the risk of lymph node metastases with a greater precision.
Pit pattern can be evaluated by means of magnification on endoscopy.
Kudos classification is used.
Type I: roundish pits
Type II: stellar or papillary pits
Type III S: small roundish or tubular pits (smaller than type I pits)
Type III L: large roundish or tubular pits (larger than type I pits)
Type IV: branch-like or gyrus-like pits
Type V: non-structured pits
M Barthet
Lecture
2 years ago
296 views
13 likes
0 comments
16:59
Staging before endoscopic resection: EMR and ESD
Pre-procedural planning before any endoscopic resection requires the assessment of the lesion. The main criteria which need to be assessed are the following:
- depth of invasion of the lesion;
- lymph node metastasis;
- lateral spread of the tumor;
- pit pattern.
Routine endoscopy is used to assess tumor size. Tumors can be staged with the use of many classifications, and notably the Paris classification.
High-frequency (≥20MHz) endoscopic ultrasonography (EUS) produces an image of the mucosal wall comprising nine separate layers differentiated by their echogenicity. Careful examination of the depth of lesion penetration into the mucosal and submucosal layers is used to determine the risk of lymph node metastases with a greater precision.
Pit pattern can be evaluated by means of magnification on endoscopy.
Kudos classification is used.
Type I: roundish pits
Type II: stellar or papillary pits
Type III S: small roundish or tubular pits (smaller than type I pits)
Type III L: large roundish or tubular pits (larger than type I pits)
Type IV: branch-like or gyrus-like pits
Type V: non-structured pits
Video case: colon cancer
Endoscopic mucosal resection (EMR) is a method for treating early gastrointestinal mucosal lesions. The procedure of EMR involves submucosal injection of normal saline or saline with a mix of methylene blue to separate the lesion from the underlying muscle layers. The raised lesions can be completely removed with a snare. EMR is a simple and safe procedure with a small learning curve.
The risk of serious complications such as perforation and bleeding is rare.
The invasion depth of the tumor can be assessed after resection using pathological examination. The recurrence rate is very low (0-3.6%) after resection. EMR is not an appropriate choice for gastrointestinal tumors (size >20mm) as the complete recurrence rate is very low and recurrence after resection is very high.
R Dumas
Lecture
2 years ago
1030 views
41 likes
0 comments
11:03
Video case: colon cancer
Endoscopic mucosal resection (EMR) is a method for treating early gastrointestinal mucosal lesions. The procedure of EMR involves submucosal injection of normal saline or saline with a mix of methylene blue to separate the lesion from the underlying muscle layers. The raised lesions can be completely removed with a snare. EMR is a simple and safe procedure with a small learning curve.
The risk of serious complications such as perforation and bleeding is rare.
The invasion depth of the tumor can be assessed after resection using pathological examination. The recurrence rate is very low (0-3.6%) after resection. EMR is not an appropriate choice for gastrointestinal tumors (size >20mm) as the complete recurrence rate is very low and recurrence after resection is very high.
Respective indications of EMR and ESD
Endoscopy has increased the detection of early neoplastic lesions of the gastrointestinal tract (GIT) known as gastrointestinal superficial lesions.
Endoscopic resection is adequate in patients with early gastrointestinal cancer with limited or completely nil submucosal involvement. Endoscopic resections are mainly used for high- and low-grade dysplasia. Most lesions can be treated using endoscopic mucosal resection (EMR), however unsuitable for lesions greater than 20mm in size. Endoscopic submucosal dissection (ESD) allows to achieve an ‘en bloc’ resection of the lesions, irrespective of the size of the tumor.
Esophagus:
Endoscopic resection is indicated for esophageal cancers with no risk of lymph node invasion. The size of the lesion is the main criterion for the choice of the procedure.
Barrett’s esophagus: EMR is the gold standard for endoscopic excision in Barrett’s esophagus; the main limitation is piecemeal resection with EMR, which makes histopathological assessment difficult, and the risk of recurrence and residual tumor is high. ESD should be considered for lesions greater than 15mm, poorly lifting tumors, and those at risk for submucosal invasion.
Stomach:
The lesions which should be considered for endoscopic resection because of a very low risk of lymph node metastasis are the following:
- non-invasive neoplasia (dysplasia) independently of size;
- intramucosal differentiated-type adenocarcinoma, without ulceration (size ≤2cm absolute indication, >2cm expanded indication);
- intramucosal differentiated-type adenocarcinoma, with ulcer, size ≤3cm (expanded indication);
- intramucosal undifferentiated-type adenocarcinoma, size ≤2cm (expanded indication);
- differentiated-type adenocarcinoma with superficial submucosal invasion.
EMR was the first treatment alternative to surgery for early gastric cancer. However, EMR is associated with a high recurrence rate (30%) according to some studies.
ESD for early gastric cancers has higher ‘en bloc’ resection rates, histologically complete resection rates, and low recurrence rates. ESD though is associated with longer operative times.
Duodenum:
The use of endoscopic resection in the duodenum and the small bowel is limited because of a high risk of perforations. EMR standard or piecemeal resections can be used for superficial lesions with perforation rates less than 5%.
Colon:
EMR represents a highly effective treatment for lesions of the colon less than 20mm in diameter. Piecemeal EMR for larger lesions reduces the quality and reliability of histopathological findings.
In the rectum, the indications for ESD may be extended for all large (>20mm), non-granular (NG) or granular lesions, or mixed laterally spreading tumors (LSTs) (>20-30mm).
ESD can be considered for the removal of colonic and rectal lesions with a high suspicion of limited submucosal invasion, which is based on two main criteria, namely a depressed morphology and an irregular or non-granular surface pattern, particularly if the lesions are larger than 20 mm.
Summary:
EMR should be the first option for the following:
- superficial lesion in Barrett’s esophagus;
- small gastric lesion
N Fukami
Lecture
2 years ago
401 views
21 likes
0 comments
29:26
Respective indications of EMR and ESD
Endoscopy has increased the detection of early neoplastic lesions of the gastrointestinal tract (GIT) known as gastrointestinal superficial lesions.
Endoscopic resection is adequate in patients with early gastrointestinal cancer with limited or completely nil submucosal involvement. Endoscopic resections are mainly used for high- and low-grade dysplasia. Most lesions can be treated using endoscopic mucosal resection (EMR), however unsuitable for lesions greater than 20mm in size. Endoscopic submucosal dissection (ESD) allows to achieve an ‘en bloc’ resection of the lesions, irrespective of the size of the tumor.
Esophagus:
Endoscopic resection is indicated for esophageal cancers with no risk of lymph node invasion. The size of the lesion is the main criterion for the choice of the procedure.
Barrett’s esophagus: EMR is the gold standard for endoscopic excision in Barrett’s esophagus; the main limitation is piecemeal resection with EMR, which makes histopathological assessment difficult, and the risk of recurrence and residual tumor is high. ESD should be considered for lesions greater than 15mm, poorly lifting tumors, and those at risk for submucosal invasion.
Stomach:
The lesions which should be considered for endoscopic resection because of a very low risk of lymph node metastasis are the following:
- non-invasive neoplasia (dysplasia) independently of size;
- intramucosal differentiated-type adenocarcinoma, without ulceration (size ≤2cm absolute indication, >2cm expanded indication);
- intramucosal differentiated-type adenocarcinoma, with ulcer, size ≤3cm (expanded indication);
- intramucosal undifferentiated-type adenocarcinoma, size ≤2cm (expanded indication);
- differentiated-type adenocarcinoma with superficial submucosal invasion.
EMR was the first treatment alternative to surgery for early gastric cancer. However, EMR is associated with a high recurrence rate (30%) according to some studies.
ESD for early gastric cancers has higher ‘en bloc’ resection rates, histologically complete resection rates, and low recurrence rates. ESD though is associated with longer operative times.
Duodenum:
The use of endoscopic resection in the duodenum and the small bowel is limited because of a high risk of perforations. EMR standard or piecemeal resections can be used for superficial lesions with perforation rates less than 5%.
Colon:
EMR represents a highly effective treatment for lesions of the colon less than 20mm in diameter. Piecemeal EMR for larger lesions reduces the quality and reliability of histopathological findings.
In the rectum, the indications for ESD may be extended for all large (>20mm), non-granular (NG) or granular lesions, or mixed laterally spreading tumors (LSTs) (>20-30mm).
ESD can be considered for the removal of colonic and rectal lesions with a high suspicion of limited submucosal invasion, which is based on two main criteria, namely a depressed morphology and an irregular or non-granular surface pattern, particularly if the lesions are larger than 20 mm.
Summary:
EMR should be the first option for the following:
- superficial lesion in Barrett’s esophagus;
- small gastric lesion
How to manage EMR/ESD resection specimen for accurate histological assessment
In this lecture, Dr. Lehr outlines the various methods of handling the resected specimens. The importance of ‘en bloc’ resection over piecemeal resection is highlighted. ESD specimens are usually resected ‘en bloc’, hence 82% of the resections are R0, and the risk of recurrence is less than 1%.
As for EMR, 48% of specimens are piecemeal. Consequently, an accurate assessment of the resection margin cannot be achieved and the risk of recurrence is greater than 6%.
The true depth of the tumor can only be assessed when the lesion is resected in one piece and with the avoidance of electrocautery injuries inside or at the edges of the lesion. The specimen must be fixed on a Styrofoam or in specialized boxes to prevent it from curling up once put in formalin.
Specimen orientation is essential in order to help the pathologist for proper examination and reporting.
HA Lehr
Lecture
2 years ago
131 views
5 likes
0 comments
22:13
How to manage EMR/ESD resection specimen for accurate histological assessment
In this lecture, Dr. Lehr outlines the various methods of handling the resected specimens. The importance of ‘en bloc’ resection over piecemeal resection is highlighted. ESD specimens are usually resected ‘en bloc’, hence 82% of the resections are R0, and the risk of recurrence is less than 1%.
As for EMR, 48% of specimens are piecemeal. Consequently, an accurate assessment of the resection margin cannot be achieved and the risk of recurrence is greater than 6%.
The true depth of the tumor can only be assessed when the lesion is resected in one piece and with the avoidance of electrocautery injuries inside or at the edges of the lesion. The specimen must be fixed on a Styrofoam or in specialized boxes to prevent it from curling up once put in formalin.
Specimen orientation is essential in order to help the pathologist for proper examination and reporting.
High-definition endoscopy and chromoendoscopy
Chromoendoscopy uses the topical application of stains or pigments to improve tissue localization, characterization, or diagnosis during endoscopy. Various stains used are as follows:
- absorptive stains: Lugol’s solution of iodine, methylene blue;
- contrast stains: indigo carmine;
- reactive stains: congo red and phenol red.
The most commonly used stains are iodine and methylene blue.
The other available advanced endoscopic technologies for lesion assessment are magnification endoscopy, confocal endoscopy, and confocal endocytoscopy. This video highlights the various types of mucosal patterns in early cancer seen with the use of high definition and magnification endoscopy.
Narrow band imaging (NBI): this is an imaging technique used in endoscopy where lights of blue or green wavelength are used to enhance the details of the mucosal pattern.
H Minami
Lecture
2 years ago
395 views
14 likes
0 comments
16:19
High-definition endoscopy and chromoendoscopy
Chromoendoscopy uses the topical application of stains or pigments to improve tissue localization, characterization, or diagnosis during endoscopy. Various stains used are as follows:
- absorptive stains: Lugol’s solution of iodine, methylene blue;
- contrast stains: indigo carmine;
- reactive stains: congo red and phenol red.
The most commonly used stains are iodine and methylene blue.
The other available advanced endoscopic technologies for lesion assessment are magnification endoscopy, confocal endoscopy, and confocal endocytoscopy. This video highlights the various types of mucosal patterns in early cancer seen with the use of high definition and magnification endoscopy.
Narrow band imaging (NBI): this is an imaging technique used in endoscopy where lights of blue or green wavelength are used to enhance the details of the mucosal pattern.