April 6, 2021

Conscious Sedation for Endoluminal Colorectal Procedures a Game-Changer

“It’s better for everyone,” surgeon says.

Endoluminal Surgery

Cleveland Clinic is pioneering the use of advanced endoscopic techniques to remove complex polyps and early malignant lesions in the digestive tract without anesthesia. Selected colorectal procedures are now performed under conscious sedation in the outpatient Endoluminal Surgery Center.

Advertisement

Cleveland Clinic is a non-profit academic medical center. Advertising on our site helps support our mission. We do not endorse non-Cleveland Clinic products or services. Policy

“We prefer to use conscious sedation when removing benign polyps and early malignant lesions that are low-risk for metastasis. Patients prefer it, outcomes are improved and procedures are less expensive,” says Cleveland Clinic colorectal surgical oncologist and endoluminal surgery pioneer Emre Gorgun, MD. “It’s really better for everyone.”

Conscious sedation is less risky than sedation with propofol or general anesthesia, particularly for patients with heart disease or other comorbid condition presenting for gastrointestinal surgery.

“Patients are able to roll over or move as requested and can adjust their own body position to remain comfortable. They awaken easily and quickly regain their balance and stability, making same-day homegoing safer,” he says.

Rapidly advancing field

Expansion of screening protocols has increased the number of patients diagnosed with nonmalignant lesions or early cancers of the colon and rectum. Traditionally, such patients are referred for surgery. The availability of endoluminal surgery and natural orifice approach is allowing a growing percentage of patients with complex colon polyps, large duodenal polyps, early esophageal cancers, gastric cancers and neuroendocrine tumors to undergo less-invasive treatment.

“In our practice, the risk of recurrence is low at 2 to 3%,” says Dr. Gorgun. “Because these patients may be at high risk for recurrence, we do a repeat scope and surveillance at six months, then follow up every three years.”

Advertisement

Early cancers can be managed endoluminally, so long as lymph node involvement is negligible or nonexistent.

“We resect these lesions en bloc and measure the depth of invasion. If it is less than 1000 micrometers, all is well. With deeper lesions the risk of lymph node involvement rises, and organ resection becomes more appropriate,” he explains.

Lesions that may leave a large defect when removed are selectively scheduled for endoscopic surgery with laparoscopic backup.

Looking ahead

Dr. Gorgun foresees the rapid expansion of endoluminal surgery as operators gain experience and devices evolve to handle increasingly complex lesions.

Several models for learning the technique have been developed, and Dr. Gorgun offers courses at Cleveland Clinic and at national meetings. “It is demanding on operators’ skills, so the learning curve is fairly steep,” he says.

Advertisement

Cleveland Clinic is partnering with device manufacturers to improve the tools needed to refine endoluminal surgery, including better scopes, tools that will facilitate endoscopic suturing and more dexterous robots. “They will make suturing safer and enable us to tackle much larger lesions,” he says.

Dr. Gorgun feels that interest in endoluminal surgery will accelerate once the sentinel lymph node for metastatic cancers is discovered. “Sentinel lymph node biopsy is key,” he says. “Currently in this country, for every four colons removed for cancer, one is removed for a nonmalignant lesion. When we discover the sentinel node, endoluminal surgery will become even more useful.”

Related Articles

Dr. Jagadeesh at Cleveland Clinic
February 28, 2024
Treating Patient with Systemic T-Cell Lymphoma and Graft-Versus-Host Disease

A case study on the value of access to novel therapies through clinical trials

Doctor measuring patient's waist size
February 26, 2024
Impact of Obesity on GVHD & Transplant Outcomes in Hematologic Malignancies

Findings highlight an association between obesity and an increased incidence of moderate-severe disease

Physician with patient
February 21, 2024
Strategies for Improving Clinical Trial Equity

Cleveland Clinic Cancer Institute takes multi-faceted approach to increasing clinical trial access

How antibody drug conjugates work
February 13, 2024
Real-World Use of Trastuzumab Deruxtecan

Key learnings from DESTINY trials

CQD-4445459-rotz-650×450
February 7, 2024
Advances in Bone Marrow Transplant Have Improved Outcomes in Fanconi Anemia

Overall survival in patients treated since 2008 is nearly 20% higher than in earlier patients

CQD-CHP4445461-hanna-sickle-650×450
February 5, 2024
Haploidentical Bone Marrow Transplant Has Durable Engraftment in Patients With Sickle Cell Disease

Two-year event-free survival comparable to matched sibling donor myeloablative transplant

24-CNR-4545611-CQD-Podcast-967×544
February 1, 2024
Possibilities of CRISPR Technology (Podcast)

Gene editing technology offers promise for treating multiple myeloma and other hematologic malignancies, as well as solid tumors

CQD-CHP4445460-hanna-sickle-650×450
January 30, 2024
Gene Therapy Trials Show Positive Results in Sickle Cell Disease and Thalassemia

First-in-human trials of CRISPR-Cas12a gene editing demonstrate safety and meaningful event-free survival

Ad