Endoscopy: From Diagnosis to Therapeutics

Ariel A. Benson, Mizrahi Meir

Division of Medicine, Institute of Gastroenterology and Liver Diseases, Hadassah-Hebrew University Medical Center, Jerusalem, IsraelIsrael
Division of Gastroenterology, Center for Advanced Endoscopy, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Ave., Boston, MA 02215, USAUnited States

DOI: https://doi.org/10.17140/goj-1-e001 · Published 2015-04-17 · Licence: https://creativecommons.org/licenses/by/4.0 · © 2015 The Author(s)

Also available as PDF (figures and tables appear in the PDF).

GASTRO Editorial Endoscopy: From Diagnosis to Therapeutics * *Corresponding author Mizrahi Meir, MD Division of Gastroenterology 1 2* Ariel A. Benson and Mizrahi Meir Center for Advanced Endoscopy Beth Israel Deaconess Medical Center and Harvard Medical School 1 Division of Medicine, Institute of Gastroenterology and Liver Diseases, Hadassah-Hebrew 330 Brookline Ave., Boston University Medical Center, Jerusalem, Israel MA 02215, USA E-mail: mmizrahi@bidmc.harvard.edu 2Division of Gastroenterology, Center for Advanced Endoscopy, Beth Israel Deaconess Medi- cal Center and Harvard Medical School, 330 Brookline Ave., Boston, MA 02215, USA Volume 1 : Issue 2 Article Ref. #: 1000GOJ1e001 Two decades ago, gastroenterologists used endoscopy for the diagnosis of Gastroin- Article History testinal (GI) lesions, thereby helping surgeons to localize lesion that necessitated resection and th Received: April 15th, 2015 treatment with surgery. Today, the gastroenterology field has advanced beyond the diagnostic th Accepted: April 15th, 2015 era and now, a large number of GI lesions can be treated via endoluminal procedures performed th Published: April 17th, 2015 by the gastroenterologist with no need for surgical intervention. In recent years, the improvement of endoscopic imaging and tools, such as snares, Citation clips and needles which can be delivered through the endoscope channel, have helped to change Benson AA, Mizrahi M. Endoscopy: from diagnosis to therapeutics. Gas- the field of gastroenterology.

This allowed for the development and advancement of Endo- tro Open J. 2015; 1(2): e1-e3. doi: scopic Mucosal Resection (EMR) and Endoscopic Submucosal Dissection (ESD). The pioneers 10.17140/GOJ-1-e001 of EMR and ESD were from Japan and the first articles describing these techniques were pub- 1,2 lished in the 1990s.1,2 Two classification systems are used for describing GI lesions to be considered for EMR and ESD. One system is the Japanese classification3 and the second is the Paris system, which was proposed in 2002.4 The Japanese classification was originally developed for early gastric cancer management, but it can be applied to lesions throughout the GI tract. Once le- sions are classified, EMR can be performed in different GI locations, including the esophagus, stomach, colon and rectum. When lesions are more complex and beyond the mucosa, ESD can be performed with careful dissection.

Endoscopic ultrasound (EUS) may be useful in deciding whether to perform EMR or ESD. EUS can aid in determining the penetration of the tumor to layers beyond the mucosa when the lesion is localized in proximal parts of the colon. If the lesion cannot be reached by a regular EUS endoscope special high frequency mini-probes may be used through the colono- scope working channel.

Two methods are used in performing EMR. The first method is ‘suck and cut’ and the second method is ‘lift and cut’. Both usually begin with a submucosal injection prior to resec- tion of the lesion the suc and cut method may be used also without submucosal injection espe- cially when being performed in the esophagus. The injection is used to expand the submucosa, separating the deeper muscolaris propria from the more superficial mucosa and submucosa layers. Several solutions may be used as the injectate. These include normal saline with or without diluted epinephrine, hypertonic saline, dextrose solution, sodium hyaluronate, fibrino- Copyright gen combination, glycerol, and fructose solutions all of those may be mixture with methylene ©2015 Mizrahi M. This is an open 5-8 access article distributed under the blue depend on the preference of the endoscopist.5-8 Conio, et al. compared the solutions and Creative Commons Attribution 4.0 showed that the disappearing time of normal saline is approximately 3 minutes with or without International License (CC BY 4.0), epinephrine, while the disappearing times of 50% dextrose and 10% glycerol and hyaluronic which permits unrestricted use, acid solutions were 4.7, 4.2 and 22 minutes respectively.

distribution, and reproduction in any medium, provided the original work is properly cited. After injection, one of the two resection methods can be applied. The ‘suck and cut’ GASTRO method utilizes a transparent cap on the endoscope and requires occur in as many as 24% of cases.18 Colonic ESD may be com- suctioning of the lesion into the cap. The lesion is then resected plicated by perforation in up to 10% of cases as reported by Ta- by a snare which exits through the working channel into the megai Y, et al.19 but in most cases the perforation may be treated transparent cap. A variation of this method is the use of bands endoscopically without the need for surgical intervention.

instead of an injection solution, and this method is best for the treatment of esophageal lesions.10 Following injection, the ‘lift In conclusion, EMR and ESD will continue to be per- and cut’ method involves the use of a grasper to pull the lesion formed worldwide, likely with increased frequency, during the from the muscolaris propria. The ‘lift and cut’ method was the next several years. Nonetheless, in order to avoid and reduce first EMR technique, but because of complexity, the ‘suck and complications, it is recommended that EMR and ESD be per- cut’ method is now used more widely.

formed at high volume centers and by experienced endosco- pists.

When the lesion is thought to be deeper or wider, if it is a submucosal lesion, or if en bloc resection is preferred, CONFLICTS OF INTEREST: None.

ESD may be used for resection. ESD includes the same inject and lift method as EMR, but instead of using a snare, needle

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