Advanced Endoscopy

Endoscopic Ultrasound (EUS) is an advanced endoscopic technique which combines the power of regular endoscopy and an ultrasound to allow for effective imaging of the digestive tract and surrounding organs and tissues, as well as the chest and abdomen. This procedure uses an endoscope with high-frequency sound waves to produce detailed images of the lining and walls of your digestive tract, pancreas, liver and lymph nodes. This procedure is used to diagnose, evaluate and determine the stage of several gastrointestinal diseases including cancer, pancreatic masses, pancreatic cysts and liver disease. Additionally, the use of EUS guided fine needle biopsy allows the safe and effective collection of tissue from difficult to reach areas.

Therapeutic EUS is rapidly expanding with a variety of therapeutic applications such as:

• Drainage of pancreatic fluid collections
• Removal of pancreatic necrosis (dead tissue)
• Drainage of other abnormal fluid collections and abscess in the abdomen
• Fully internal EUS-guided bile duct and gall bladder drainage
• ERCP for gastric bypass patients
• Precise targeting and direct delivery of medications into the pancreas, liver and other adjacent organs
• Nerve block for pain management in pancreatic diseases
• Localized therapy for pancreatic tumors/cysts
• Treatment of subepithelial (located beneath an epithelial layer) lesions and gastric varices

Endoscopic mucosal resection (EMR) is performed to remove abnormal (dysplastic) tissue in the surface (mucosal) layer of the gastrointestinal tract wall. An endoscope is a long tube with a light and camera at the end. Small tools are passed through the scope to remove the abnormal tissue. This is a minimally invasive endoscopic procedure, which can be performed instead of surgery in some cases. EMR is used for abnormal lesions of the esophagus, stomach, small bowel and colon.

For lesions in the colon, the endoscope is guided up through the rectum. For lesions in the upper digestive tract, the endoscope is guided through the mouth.

EMR can be most effective when used to treat:

• Areas with abnormal tissue, precancerous (dysplastic) lesions or superficial cancers such as esophageal, gastric or small bowel lesions
• Barrett’s esophagus with dysplasia
• Early-stage esophageal cancer or colon cancer

This procedure uses a specialized endoscope to insert dye into the bile ducts (tubes that drain bile from the liver and gallbladder into the intestine) and pancreatic duct (tube that drains pancreatic juice into the intestine) under X-ray guidance. Several therapies are available through ERCP if a defect is identified. Common conditions in which ERCP is performed is for the removal of common bile duct stones, placement of stents in pancreatic cancer and bile duct cancers and treatment of chronic pancreatitis.

ERCP is a highly complex procedure. The success rate and outcomes are better when the procedure is performed by highly experienced physicians and teams. On average, our team performs more than double the number of ERCPs than any other program in Connecticut and with significantly higher outcomes.

Endoscopic Submucosal Dissection (ESD) is a minimally invasive procedure performed to remove abnormal (dysplastic) lesions and early cancers (tumors) from the surface layers of the gastrointestinal tract. This procedure has many potential benefits for those diagnosed with early esophageal, gastric or rectal cancer. ESD uses special techniques to remove early tumors in one piece and is used to treat the following tumors and lesions:

• Barrett’s esophagus with advanced dysplasia
• Early-stage tumors of the intestinal tract (colorectal cancer, stomach cancer and esophageal cancer)

Through an endoscope, instruments are passed through a tube and precisely cut the tumor, typically removing it in a single piece. ESD may avoid the need for surgery and very accurately identifies patients whose lesions definitively require surgery.

How do I prepare for EMR and ESD?

Your physician will provide detailed instructions on how to properly prepare for your EMR procedure. Some steps to take before the procedure may include:

• For EMR and ESD of the upper GI tract, do not eat or drink for 12 hours before the procedure to ensure your esophagus is clear. 
• For EMR and ESD of the lower GI tract with colonoscopy, a bowel preparation to clean the colon is required. Instructions for bowel preparation will be provided. 
• You will need someone to drive you home after your procedure since you will receive medication that will make you sleepy or groggy.
• Follow your physician’s preparation instructions carefully. Call your physician’s office if you have questions about the preparation.
• The medical team will review your medications to determine if any medications that thin the blood can be safely paused.

What happens during an EMR and ESD procedure?

• An IV is inserted for sedation.
• The endoscope is guided through your mouth or your rectum, depending on the location of the tumor.
• Images from the endoscope camera display on a screen.
• The tumor is separated from the underlying layers of the intestinal wall with a temporary fluid injection.
• A thin wire is passed through the endoscope and looped around the base of the tumor and an electric current in the wire cuts away the tumor and seals the cut at the same time.
• The tumor is removed through the endoscope or with a specialized retrieval tool.
• A tissue sample is sent to the laboratory for examination by a pathologist.

Endoscopic therapy can prevent Barrett’s esophagus with dysplasia (an abnormal premalignant change in the cells) from progressing to cancer. This abnormal area can be thick and nodular or flat in appearance. Using an endoscope, your advanced gastroenterologist will remove any thickened abnormal tissue from the esophagus using a technique of Endoscopic Mucosal Resection (EMR) or Endoscopic Submucosal Dissection (ESD). A pathologist will then evaluate the tissue and confirm that the dysplastic growth was removed. Once the thickened nodular area has been removed, the rest of the flat Barrett’s esophagus is treated by an endoscopic ablation technique such as radio-frequency ablation (RFA), cryotherapy or hybrid APC (Argon Plasma Coagulation).

Dysplasia is given a grade by the pathologist using the following guidelines:

• High-grade dysplasia: cells show advanced changes and have a high risk of progressing to cancer if not treated
• Low-grade dysplasia: cells demonstrate precancerous changes with a lower risk of progression
• No dysplasia: if Barrett's esophagus (intestinal metaplasia—where a more acid resistant type of cells has moved location to the lower esophagus) is present, but no precancerous changes (dysplasia) are found in the cells
• Not definitive for dysplasia: the pathologist cannot determine if the changes in the cells are due to inflammation or dysplasia. Typically, the physician will prescribe acid blocking medication, and schedule a repeat biopsy in 6 months. 

Patients with Barrett’s esophagus with low or high-grade dysplasia are shown to have a lower risk of progression to cancer following endoscopic therapy for Barrett’s esophagus.

Other treatment therapies for Barrett’s esophagus:

Cryotherapy

Cryotherapy is a treatment that applies extreme cold, created with the use of liquid nitrogen or argon gas, to freeze and destroy abnormal tissue. For Barrett’s esophagus, this is applied using a catheter passed through an endoscope.

Hybrid Argon Plasma Coagulation (APC)

Hybrid argon plasma coagulation (APC) for Barrett’s esophagus combines the creation of a submucosal fluid condition with the injection of saline with APC ablation of the overlying Barrett’s mucosa.

Radiofrequency ablation (RFA)

Radiofrequency ablation for Barrett’s esophagus, or RFA, is the endoscopic application of heat energy to remove the Barrett’s mucosal lining and convert it back to a normal lining.

To refer a patient for consultation, call 203-200-5083.

During a Peroral Endoscopic Myotomy (POEM) procedure, a flexible tube, or endoscope, is inserted through the mouth and when it reaches the esophagus, an incision is made from the esophageal wall to the muscle. Once the muscle is reached, the endoscopist creates a downward tunnel towards the connection between the esophagus and the stomach. Certain muscles are divided to help ease the passing of food and drink into the stomach from the esophagus. After the procedure, a barium contrast study is performed to ensure normal swallowing function has returned.

Endoscopic Ultrasound (EUS) is minimally invasive advanced endoscopic technology where a special endoscope uses high frequency sound waves to produce detailed images of the gastrointestinal tract and nearby structures. Therauptic EUS is rapidly expanding with a variety of therapeutic applications such as:

• Drainage of pancreatic fluid collections
• Removal of pancreatic necrosis (dead tissue)
• Drainage of other abnormal fluid collections and abscess in the abdomen
• Fully internal EUS-guided bile duct and gall bladder drainage
• ERCP for gastric bypass patients
• Precise targeting and direct delivery of medications into the pancreas, liver and other adjacent organs
• Nerve block for pain management in pancreatic diseases
• Localized therapy for pancreatic tumors/cysts
• Treatment of subepithelial (located beneath an epithelial layer) lesions and gastric varices