Med Journal October 2020 - Page 4

Commentary by benjamin tharian , md , mrcp , facp , fracp , fasge

Gastrointestinal endoscopy involves a variety of procedures to diagnose diseases of alimentary canal ( esophagus , stomach , duodenum , small and large bowel ) with the help of camera attached to a tube ( endoscope ). Advanced endoscopy includes procedures which are beyond the scope of a regular endoscopy and requires high innovation , persistence , and ability to manage complication with controlled aggression .
According to Center for Disease Control ( CDC ), some of the alimentary canal tumors such as esophageal cancer , colorectal cancer have higher incidence and mortality in Arkansas compared to rest of the U . S . This could be due to lack of access to endoscopy centers and decreased awareness of cancer screening procedures . However , with the availability of more gastroenterologists in the state , ability for cancer screening ( colon and rectal ) has been increasing . Advanced endoscopy takes one more step to access various parts of the gastrointestinal tract .
Previously , surgery was the main modality to assess , diagnose , and formulate a plan of treatment for the bile duct , gallbladder , and small bowel . However , with the availability of advanced ultra-slim cameras , ultrasounds , and imaging , the ability to access these difficult areas of the gastrointestinal tract has become possible without surgery .
Recently , I took care of a 50-year-old software engineer , a technically savvy individual who came to my clinic with some sticking sensation in his food pipe . His initial workup showed that he had a small thickening in the middle part of the esophagus . He was diagnosed with esophageal cancer , early type , restricted to the first layer ( mucosa ). It was a superficial cancer of the esophagus . He performed an extensive research given his internet skills and was significantly concerned about his life ahead . The news of cancer shell-shocked him . His research on the internet showed esophageal cancer had worse outcomes . He was depressed . However , with the role of advanced endoscopic procedures , cancers restricted to superficial layers ( mucosa or submucosa ) could potentially be targeted with advanced techniques ( Endoscopic Mucosal Resection [ EMR ], Endoscopic Submucosal Dissection [ ESD ]) in centers with high endoscopic expertise . His esophageal lesions were removed and his cancer cured . He was very grateful that his cancer was treated without major surgery or chemotherapy .
Similarly , I recently evaluated a physician from out-of-state who came to UAMS to get an evaluation concerning stomach pain . He had initial workup of his stomach with endoscopy and was diagnosed with a small fat tumor ( lipoma ), which was benign and not cancerous . However , his symptoms were still present . He requested that I have a second look at his symptoms . We performed a repeat procedure and found that the fat tumor was unusual in its appearance ; hence , an ultrasound was attached to the endoscope ( Endoscopic Ultrasound [ EUS ]) and revealed that the benign tumor was atypical with a suspicion for cancer . We took a sample of this tumor and analyzed it microscopically , revealing a rare cancer that was then removed completely by surgery . The technique of EUS helped us to diagnose and stage the cancer in its early part , which resulted in the removal and potential cure .
With advances in the development of minute ultrasounds , we can access the bile duct , target stones in the bile duct that are difficult to remove , and access gallbladder and small bowel . Special procedures like EUS are used to take samples for microscopic analysis from any organs ( nodes , tumors ) surrounding the gastrointestinal tract . They could potentially be used to relieve pain ( by targeting nerve supply ) and jaundice ( by relieving blockage ) in
Director of General and Advanced Endoscopy , Assoc . Prof of Medicine , UAMS , Little Rock , Ark .

Curing Early Cancer : Role of Advanced Endoscopy

advanced pancreatic cancer . They could be used to target early cancerous lesions , potentially curing them .
The Future Awaits
These minimally invasive procedures are used to access internal gastrointestinal tract with no skin incisions . This results in faster recovery time , no scars , reduced blood loss , and – eventually – patients walking out of the hospital on the same day after the procedure . With the advent of these new techniques – and the ability to target the esophagus , stomach , and colon cancers – we anticipate a paradigm shift in detecting tumors at an early stage and removing them , resulting in increased cure .
In the future , robotic technology with virtual reality will have a significant role in enhancing and improving these techniques . Virtual techniques , using high-tech software and state-of-the-art stimulators , have resulted in significant advances in training with minimal risk to the patient . This should help trainees early in their career to develop and enhance their visual and technical knowledge in reaching parts of the gastrointestinal tract that were never thought to be a possibility before . With the use of robotic-assisted techniques , future gastroenterologists should be able to integrate and treat with minimum discomfort to the patient .
76 • The Journal of the Arkansas Medical Society www . ArkMed . org