For patients with complex benign colorectal polyps, surgical intervention tends to be the norm. Yet, endoluminal procedures like endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) offer better alternatives.
Many studies have documented that an endoscopic approach for ESD is a safer and less expensive alternative to removing these polyps, leading to fewer postoperative complications and shorter hospital stays.
Becker's Healthcare recently spoke with three leading gastroenterologists about the benefits and challenges associated with advanced endoscopic procedures.
- David Diehl, MD, Geisinger Medical Center, Danville, Pa.
- Sergey Kantsevoy, MD, Director, the Center for Therapeutic Endoscopy, Mercy Medical Center, Baltimore
- Mohamed Othman, MD, Baylor St. Luke's Medical Center, Houston
Successful endoluminal procedures require innovative technologies and techniques
Studies have revealed that nearly half of all colonic lesions referred to surgeons are benign polyps. As many as one-third to one-half of those cases would be better candidates for EMR than traditional surgery. Fortunately, more gastroenterologists and surgeons are learning about the value of endoluminal procedures and are referring patients to the appropriate specialists.
"Most of the referrals that I receive for complex colonic polypectomy are from gastroenterologists," Dr. Diehl said. "However, I also receive referrals from colorectal surgeons who re-refer cases to me for endoscopic treatment, rather than a surgical resection. This is the 'right thing to do.' Surgical treatment should be reserved only for polyps that can't be removed endoscopically or in cases of malignancy."
Patients have also become more knowledgeable about their options and some serve as their own advocates. "Many patients research treatment options on the internet and talk to other people," Dr. Kantsevoy shared. "Eventually, these patients find me and come for endoscopic removal of these lesions. Individuals have traveled from all over the United States, including California, Texas and more, for procedures with me."
Although endoluminal procedures offer many benefits to patients, they also present certain challenges to clinicians, especially large, flat polyps for instance.
"Most of the complex colon polyps referred to me for management are sessile or flat and are larger than 20 millimeters," Dr. Diehl said. "It's not uncommon for these polyps to be as large as 35 millimeters or more. When flat polyps extend over colon folds, it can be challenging to achieve complete resection. My goal is to achieve complete resection during my first procedure, if possible. To accomplish this, I often rely on newer technologies."
Depending on the clinical presentation, physicians may utilize an expanded toolkit of devices, techniques, and approaches. As Dr. Diehl noted, it is no longer enough to simply "lift and cut" a polyp. New innovative technologies can help make these procedures safer, faster and less labor intensive.
Overtubes in combination with endoscopes represent a "back to the future" technology for endoluminal procedures
In the early days of therapeutic colonoscopy, physicians widely used overtubes to assist with the advancement and positioning of the colonoscope. Over time, colonoscope improvements and increased expertise has rendered older generation overtubes obsolete.
Today's newer, advanced devices with overtube capability are helpful for facilitating endoscopic interventions. Lumendi's DiLumen® platform, for example, delivers value by improving several aspects of endoluminal procedures. It can simplify scope insertion in patients with a tortuous colon. Use of the balloons helps to straighten the left colon, allowing passage of the colonoscope to any part of the colon, which might otherwise be unreachable.
Dr. Othman pointed out that DiLumen stabilizes the area of the colon that the physician is working on, which is essential for achieving good results with endoscopic resection. "With the added traction which helps expedite the submucosal dissection," Dr. Othman said, "the DiLumen platform addresses the majority of endoscopic resection challenges we can encounter during such procedures. These advantages will allow for a more rapid adoption of endoscopic endoluminal techniques."
The platform's colonic overtube can function as a conduit to allow removal of both the scope and resected tissue, followed by scope reinsertion without losing position in the colon.
"There are many cases in which experienced endoscopists find added value with using the platform's overtube, to make their procedures more efficient, by allowing for optimal colonoscope positioning," Dr. Diehl said. "Efficiency is a value that can't be understated for accomplishing a complex colonic procedure."
In particular, the DiLumen EZ Glide platform offers significant improvements in usability for the DiLumen platform. "DiLumen EZ Glide eliminates friction between the outer surface of the colonoscope and the inner surface of DiLumen," Dr. Kantsevoy said. "It dramatically improves advancement of a colonoscope and eliminates the need for lubrication inside the DiLumen."
Looking ahead, experts believe that Lumendi’s innovative devices will become the standard of care for endoluminal procedures. "The difference in ease of use with EZ Glide is huge and has encouraged me to utilize the DiLumen platform more often for complex colon polypectomies," said Dr. Diehl.