New endoscopic procedure

20.04.2010 16:45

Remove cancer in the esophagus, stomach and rectum without surgery

Cancers in the stomach, esophagus and rectum can also be removed without surgery. With a technology developed in Japan and currently gaining ground in Germany, even larger mucosal tumors can be separated using an endoscope. Experts will present the procedure at the 40th Congress of the German Society for Endoscopy and Imaging Techniques (DGE-BV) in Hanover.

“Endoscopic submucosa dissection (ESD) is always possible when the cancer is still limited to the mucous membrane,” explains conference president Professor Dr. med. Jürgen Hochberger, who carries out the procedure at the St. Bernward Hospital in Hildesheim. The procedure is carried out using a highly flexible, small finger-thick endoscope under light sedation.

First, the doctor marks the extent of the tumor. He then injects fluid under the mucous membrane using a fine needle. This lifts the tumor from the ground. Now the doctor can remove it from the sides in one piece. What sounds simple is, in practice, a difficult undertaking because the doctor is not allowed to cut through the wall of the stomach, esophagus or rectum.
ESD was developed in Japan.

“Stomach cancer is much more common there than in Germany and early detection through gastroscopy has been common practice for many years,” reports Professor Hochberger: “The doctors were looking for a method to spare patients an operation.” The solution is ESD. Initially, only smaller tumors were removed. Today, tumors measuring two centimeters or more are regularly removed.

Several thousand patients have already been treated in Japan and Korea. In Germany there are significantly fewer. A Germany-wide ESD registry has been collecting the experiences of German doctors since August 2008. In the first year, 13 clinics reported 68 operations. 56 were carried out on the stomach and esophagus, the remainder in the colon. Everything didn't always go smoothly: four patients suffered a perforation of the intestinal wall. The patients had to undergo ESD surgery three times.

The registry in Germany is therefore important in order to determine which patients are eligible for treatment and how complications can be avoided. The operation in the esophagus is particularly demanding. The heartbeat is transmitted to the wall of the esophagus and the muscles' own movements also make treatment more difficult. To date, Professor Hochberger has treated five patients in the esophagus, over 30 in the rectum and around 20 in the stomach with ESD.

He managed to partially remove extensive changes in Barrett's esophagus. This is damage to the mucous membrane as a result of long-term acid and bile reflux into the esophagus, which, however, is only accompanied by heartburn and pain in around 50 percent of patients.

Hochberger removes both the mucous membrane cancer and the risk mucous membrane in which the early cancer developed in one piece. The largest resection measured 16 by 10.3 cm, of which 7 cm was in the esophagus and the rest in the stomach as a so-called R0 resection. However, not all problems are always resolved for the patient after ESD.

If the mucosal cancer has already reached the lymphatic vessels, major surgery may be necessary to reach the surrounding lymph nodes. Fortunately, this is only the case for less than 10 percent of the changes that were removed by ESD. In contrast to previous endoscopic removal techniques, which can only remove large-scale mucosal changes in numerous small pieces, ESD significantly reduces the local recurrence rate from 20 to 35 percent to less than 3 percent. Which patients can benefit from ESD and the first results of the German ESD Register are the topics of several events as part of the 40th DGE-BV Congress.