Removal of superficial tumours in oesophagus by endoscopy can avoid complete extirpation of this part of the digestive tract

The technique, carried out at the University Hospital of Navarra for the last three years, was presented at the VI International Course on Therapeutic Endoscopy in the Digestive System, organized by the Digestive System Service at this hospital. Specifically, more than 90% of patients treated for this ailment at the University Hospital of Navarra have not needed the extirpation of the oesophagus.

400 specialists from ten different countries attended the course, focusing on the therapeutic possibilities of endoscopy in the digestive system. Treatment using digestive endoscopy, without having to carry out surgery, is increasing. These applications are less aggressive than surgical operations and are undertaken at out-patient clinics in about 99% of the cases, which usually enables the patient to go home after the walk-in/walk-out treatment, explained Doctor Miguel Ángel Muñoz Navas, Director of the Digestive System Service at the University Hospital of Navarra.

As is known, endoscopy is a technique carried out using a tube-like instrument which contains a light and a lens at its tip. The tube has, moreover, a duct for carrying other instruments with which, amongst other operations. biopsies, extirpation of polyps, injection of contrasting fluids, insertion of prostheses and clips, coagulation of bleedings, extraction of stones from the biliary or pancreatic zone and the draining of abscesses may be undertaken. There are also exists an ecoendoscope, which is one incorporating an ecograph at its end. While in a normal ecography the transducer of the ecograph is outside the body, ecoendoscopy provides better quality images of a lesion that is close to the digestive tract. From the digestive tract we can observe lesions in its vicinity and access them.

Extirpation of oesophageal tumours

As regards the technique for the extirpation of distal tumours of the oesophagus undertaken at the University Hospital of Navarra, Doctor Muñoz explained that this was effective when the carcinoma occurs at surface layers. “The oesophagus is made up of three layers: mucous, sub-mucous and muscular. When the tumour is located in the mucous, we can take it out completely in most cases and thus avoid extirpation of the oesophagus. Until recently patients with this ailment – although affecting only the primary layers – were recommended the total extirpation of the oesophagus, which involved surgery with a high morbidity risk and even death”.

In any case, according to the Director of the Digestive System Service at the University Hospital of Navarra, Doctor Miguel Ángel Muñoz Navas, sometimes a surgical operation is inevitable. “There are times when you have to operate but there are others when a solution with endoscopy can be tried. But, in this case, monitoring of the patient has to be undertaken. It could be the case that we extirpate a tumour with endoscopy and the anatomopathology shows up the fact that the cancer is more infiltrated than had been thought from the biopsies or the ecoendoscopy. In these cases a surgical operation is required. Our experience has shown that more than 90% of patients that we have treated with this technique have not needed subsequent surgery”.

Extirpation of oesophageal tumours using endoscopy is not a very widespread treatment, in part due to its complexity. Nevertheless, it is a real possibility – and scientifically recognised – avoiding the extirpation of the oesophagus. Moreover, the technique can be applied in a walk-in/walk- out manner.

Surgery through natural orifices

Amongst other advances within the sphere of therapeutic digestive endoscopy, on the course organised by the Digestive System Service at the University Hospital of Navarra, surgical operations have been carried out using natural orifices, known as NOTES (natural orifice transluminal endoscopic surgery). Access can be through the buccal cavity, the anus, the vagina and the urinary bladder, the most commonly used routes being oral and vaginal. With the same endoscopy we usually use we can get to the stomach, perforate it and enter the abdominal cavity in order to, for example, extirpate a vesicle or deal with other lesions. Currently in this type of surgery, endoscopy and laparoscopy are being combined.

Endoscopic treatment has also been used in obesity cases. For patients with morbid obesity who do not respond to dietetic treatment, it is common to have recourse to bariatric surgery. This can be aggressive and, from time to time, news stories appear about patients who have died as a consequence of such operations. Such mortality is due, in part, to the fact that these patients are in a bad state of health generally and may have other diseases associated with obesity. They are beginning to work with the possibility of reducing the size of the stomach via endoscopy and of short-circuiting the intestinal loops.

Another novel application presented at the course involves therapeutic endoscopy in the biliary and pancreatic ducts. Despite the small diameter of these ducts, a new technology enables them to be accessed in order to examine them directly and to apply therapeutic techniques.

The Digestive System Service at the University Hospital of Navarra has presented a technique for draining the vesicle directly into the stomach by means of ecoendoscopy; as the Director of the Service explains: when the vesicle is very inflamed it is not possible to carry out surgery and it is less aggressive to access the organ by perforating the stomach and draining the contents of the vesicle into the stomach.

In the session devoted to the diagnostic application of endoscopy, the possibilities of carrying out direct microscopy were considered. Although it does not substitute biopsy, this technique is a complement in deciding where to take samples or in being more certain that a lesion found during examination is a malignant tumour or not.