Endoscopic Resection/Third Space Endoscopy

Endoscopic Resection

Endoscopic Mucosal Resection

Endoscopic mucosal resection is a technique that can be used to remove lesions that are in the GI tract and have not extended outside the walls of the GI lumen. The procedure starts by injecting a substance to thicken the wall underneath the lesion and create a fluid cushion, after which the lesion can be removed safely. This procedure can be done in the esophagus, stomach, small intestine, and large intestine.

Endoscopic Submucosal Dissection

Endoscopic submucosal dissection (ESD) was developed in Japan to resect early stage gastrointestinal tumors. This technique can be used for tumors or lesions that are within the walls of the GI lumen but extend into the deepest portion of the wall. It involves the use of special knives to cut away the lesion very precisely, removing the lesion without disrupting the integrity of the gastrointestinal wall. The technique represents a significant advance in therapeutic endoscopy to allow for more accurate pathological assessment and enhanced curability. The major advantages of the technique in comparison with polypectomy and endoscopic mucosal resection (EMR) are the ability to remove deeper lesions all in one piece (en bloc). This procedure can be done in the esophagus, stomach, small intestine, and large intestine.

Endoscopic Full Thickness Resection: EFTR

EFTR is a technique that allows for removal of gastrointestinal lesions that extend from inside the lumen all the way through the wall. The technique is similar to the resection technique of ESD; however, a hole is made in the gastrointestinal tract during the procedure in order to remove the lesion. At the conclusion of the procedure, it is closed from the inside using small metal clips or endoscopic sutures without the need for surgery. This procedure can be done in the esophagus, stomach, small intestine, and large intestine.

Submucosal Tunneling with Endoscopic Resection (STER)

STER is a novel technique in which a tunnel is created between the walls of the gastrointestinal lumen underneath a tumor. An endoscope can then be advanced through the tunnel until it is directly under the tumor. The tumor can then be removed from inside the tunnel, and the entrance to the tunnel can be closed internally without the need to perform surgery.


Third Space Endoscopy

Peroral Endoscopic Myotomy (POEM) for achalasia and other esophageal motility disorders

POEM is an endoscopic procedure used to treat swallowing disorders, most commonly Achalasia. These disorders are often due to a tightening, or abnormal contraction, of the muscles of the esophagus. In this minimally invasive procedure, the muscles of the lower esophageal wall and the gastroesophageal sphincter (the connection point between the stomach and the esophagus) are opened up to provide less resistance for food to go down into the stomach. This is done by creating a tunnel between the walls of the esophagus then advancing an endoscope into the tunnel and cutting the muscle layer from inside the tunnel. The tunnel opening is then closed to restore the integrity of the esophagus lumen. POEM has been shown to be associated with faster recovery and less post procedure pain when compared to its surgical alternative, Heller Myotomy. Dr. Michel Kahaleh has performed more than 500 POEMs all over the world and has been teaching this procedure all over Latin America where the prevalence of achalasia is very high.

Gastric Peroral Endoscopic Myotomy (G-POEM) for gastroparesis

G-POEM is a novel procedure used to treat a condition called gastroparesis. This is when the stomach muscles do not contract properly and it is thus difficult for food to be propelled out of the stomach into the small intestine. A G-POEM works by cutting the muscles of the pylorus, the connection point between the stomach and small intestine, to allow for easier passage of food. The procedure is done by creating a tunnel between the walls of the stomach, then advancing an endoscope into the tunnel and cutting the muscle layer from inside the tunnel. The tunnel opening is then closed to restore the integrity of the stomach lumen. In a clinical study co-authored by members of our team, this procedure has been shown to have an 85% improvement rate with a decrease in the gastroparesis cardinal symptoms index (GCSI) symptom score at follow-up.

Zenker’s Diverticulum Septotomy

A Zenker's diverticulum, or pharyngeal pouch, is an outpouching of the mucosa of the esophagus just beyond the throat where food first enters. A Zenker's diverticulum can cause inability to eat, recurrent lung infections from aspiration of food that sits in the pouch and eventually comes back up instead of going down into the stomach. A Z-POEM involves opening up the pouch by cutting the septum that separates it from the esophageal lumen, in essence marsupialization of the pouch into the esophagus to prevent food from accumulating there. This procedure is extremely successful and is associated with rapid recovery.