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What is advanced therapeutic endoscopy?
- Advanced therapeutic endoscopy is a group of techniques that are minimally invasive and organ sparing, and yet can diagnose, remove, and treat benign lesions and early malignancies of the gastrointestinal (GI) tract without need of traditional surgery using endoscopy.
What are the major advanced therapeutic endoscopy techniques?
A. Endoscopic mucosal resection (EMR) can remove mucosal lesions of the GI tract en bloc that are less than 2 cm (or piecemeal if larger than 2 cm). The EMR technique may employ the use of a cap at the tip of the scope and suction to retract the lesion into the cap and subsequent removal by electrocautery snare or submucosal injections with various solutions to raise the lesions to provide fluid cushion for safe dissection
Submucosa Injection Solutions
| Solution | Cushion Durability | Comments |
|---|---|---|
| Normal saline | Short | Easy to inject, cheap, dissipates quickly |
| Hypertonic saline 3% | Moderate | Easy to inject, cheap, tissue damage |
| Hydroxypropyl methylcellulose 0.83%-1.25% | Extended | Long lasting, relatively cheap, safe and effective, may cause tissue damage |
| Hyaluronic acid 1% | Extended | Long lasting, expensive, safe and effective, special storage |
| Dextrose 50% | Moderate | Easy to inject, cheap, tissue damage |
| Albumin 25% | Moderate | Easy to inject, expensive, safe |
B. Endoscopic submucosal dissection (ESD) can remove mucosal lesions en bloc that are larger than 2 cm, that are flat, or that are in the deeper layers (submucosa) of the GI tract and cannot be removed by other endoscopic methods. It uses an electrocautery needle knife with high cutting power to make a circumferential cut around the lesion and dissect the base of the lesion through the deeper submucosal layer. Submucosal injections are used to provide fluid cushion for dissection. Adding dye (indigo carmine or methylene blue) to injection solutions helps to identify the submucosal layer to determine margins of dissection. An example of the ESD technique to remove a large sessile mass in the cecum.
C. Advanced endoscopic ultrasound (EUS) is used to diagnose and treat lesions within the GI tract and in close proximity to the GI tract by making use of ultrasound for guidance. Some indications for advanced EUS include sampling of suspected malignant lesions or lymph nodes with EUS-guided fine-needle aspiration (FNA), drainage of pancreatic or peripancreatic fluid collections, such as pancreatic pseudocysts. With EUS-guided fine-needle injection (FNI) celiac plexus neurolysis (CPN) (block for pain control) for pancreatic cancer or chronic pancreatitis can be performed. Other applications of EUS-FNI include botulinum injection for achalasia, and EUS-FNI of antitumor agents for locally advanced pancreatic cancer.
