October 17, 2014/Digestive/Resource

Help for GI Tract Diseases

POEM, ESD among new group’s minimally invasive offerings

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Today, many GI tract diseases that once required surgery can now be treated without incisions. At Cleveland Clinic, a new Developmental Endoscopy Group can help your patients with conditions ranging from motility disorders — such as achalasia — to esophageal, gastric and colorectal cancer.

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“This new effort combines laparoscopy and endoscopy, which have traditionally been separate groups,” explains Matthew D. Kroh, MD, Director of Surgical Endoscopy in Cleveland Clinic’s Digestive Disease Institute. “Now we have a core group of interventional endoscopists who are embarking on these procedures — functionally operating through the endoscope.”

The Developmental Endoscopy Group, a fusion of gastroenterology, general surgery and colorectal surgery experts, is headed by both Dr. Kroh as Surgical Director and Mansour Parsi, MD, MPH, as Medical Director.

The main focuses to date are peroral endoscopic myotomy and endoscopic submucosal dissection. Here is a closer look at each:

POEM FOR ACHALASIA

Peroral endoscopic myotomy (POEM) is an entirely endoscopic procedure to treat achalasia. The technique originated in Japan and has been performed in the U.S. for approximately two years.

“Through the esophagus, we make a small incision in the mucosa and make a tunnel underneath it,” Dr. Kroh explains. “Then, we cut the muscles in the esophagus — mainly at the lower esophageal sphincter — which are too tight in achalasia. It’s an effective way to release this tension and restore the ability of food to pass through the esophagus and into the stomach.”

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The Developmental Endoscopy Group has successfully completed its first series of POEM patients. Advantages include requiring no incisions and patients returning home the following day. Early data for POEM are compelling, Dr. Kroh says. “It results in dramatic relief of achalasia symptoms — as good as a surgical (Heller) myotomy, without the potential morbidity associated with the incisions on the abdominal wall,” he says.

Cleveland Clinic advanced endoscopist Madhu Sanaka, MD, underwent POEM training in Japan under Haroue Inoue, MD, who pioneered the POEM procedure. Dr. Sanaka performs POEM procedures along with Cleveland Clinic thoracic surgeon Siva Raja, MD, who specializes in esophageal surgeries. Dr. Sanaka says, “Gastroenterologists and surgeons bring different skill sets to the table, which translates into the best possible care for the patient.”

ESD FOR GI CANCERS

Endoscopic submucosal dissection (ESD) allows for the removal of early esophageal, gastric and colorectal cancers through an endoscope while avoiding more invasive surgery. This technique was developed in Japan where early gastric cancer is common.

At Cleveland Clinic, gastroenterologist Amit Bhatt, MD, underwent intensive ESD training in Japan thanks to grants from the American College of Gastroenterology and the American Society of Gastrointestinal Endoscopy.

Dr. Bhatt says ESD is valuable in the treatment of early gastric and esophageal cancer. It allows for a complete one-piece resection of cancers allowing pathologists to verify curative resection similar to a surgically removed tumor — an opportunity that is missed with other endoscopic ablation techniques.

The goal of ESD is to be curative. But, Dr. Kroh adds, if it is not possible to remove the cancer with negative margins and avoid an operation, ESD gives the team a better idea of how advanced the disease is prior to surgical intervention: “For instance, when a surgeon and a gastroenterologist do a gastric case together, the beauty of it is that even if it doesn’t come out endoscopically, the patient can still get the next less invasive technique.”

Dr. Bhatt emphasizes that the collaboration between gastroenterologists and general surgeons is a remarkable benefit to patients who now have another option to avoid a traditional intervention. “Having an advanced endoscopist and a surgeon work side by side allows us to combine our expertise, ideas and innovations to develop novel approaches to problems,” Dr. Bhatt explains.

Dr. Sanaka, who also performs ESD procedures for neoplastic lesions in the GI tract, adds that ESD is less invasive compared with surgery but has similar outcomes.

The Developmental Endoscopy Group has effectively used ESD for both gastric and colorectal cancers over the past six months.

ESD FOR COLORECTAL LESIONS

In the U.S., only a few centers are using ESD to remove large colonic polyps. At the Digestive Disease Institute, Emre Gorgun, MD, has been using the technique for removing such polyps — especially flat colonic lesions — for the past three years.

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Dr. Gorgun, who received his ESD training in Japan, was one of the first U.S. colorectal surgeons to successfully remove intraluminal lesions en bloc through the anus using ESD. Overall, he says, ESD is safe and useful in carefully selected patients.

“ESD is helping us provide better healthcare and avoid bowel resection,” Dr. Gorgun says. He hopes that ESD will become more widely utilized, citing data he presented at the last American Society of Colon and Rectal Surgeons meeting that only 9 percent of polyps removed over a five-year period were actually cancerous.

“So basically 91 percent of the time, these benign lesions were overtreated with colectomy,” he explains. “If you could remove these lesions with a procedure such as ESD, the patient would be perfectly treated and the colon would be saved.”

For difficult colonic lesions, Dr. Gorgun also utilizes laparoscopic mobilization of the colon performed with combined intraoperative CO2 colonoscopy. Called combined endoscopic-laparoscopic surgery (CELS), this new approach allows removal of difficult colonic lesions via a dual technique avoiding formal bowel resection. CELS is safely offered to selected patients with benign polyps or early colonic neoplasms that could not purely be removed via colonoscopy. This combined approach is successfully performed at Cleveland Clinic by Dr. Gorgun with good outcomes.

To refer a patient to our Developmental Endoscopy Group, call 855.REFER.123.

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