Role of endoscopy in git cancers

1. Ihab Samy MD. Surgical Oncology
Lecturer of Surgical Oncology
National Cancer Institute- Cairo University
2013

2. Barrett’s Esophagus (BE)
 BE has been defined in the United States by the
presence of specialized intestinal metaplasia of the
tubular esophagus and is recognized as a precursor
lesion to esophageal adenocarcinoma (EAC)
 It is a reparative response to reflux induced damage
to the native squamous epithelium, with subsequent
replacement with a metaplastic intestinalized
epithelium, BE.
 Metaplastic BE is associated with increased cellular
proliferation and turnover that may result in
progression to dysplasia.
Dr. Ihab Samy 2013

3.  It was reported up a 30- to 40-fold
increased risk of the development of EAC
 BE is histologically graded as:
1. Nondysplastic (NDBE)
2. Indeterminate-grade dysplasia (IGD),
3. Low-grade dysplasia (LGD)
4. High-grade dysplasia (HGD)
5. Intramucosal carcinoma (IMC)
6. Invasive EAC
Dr. Ihab Samy 2013

4.  BE has a characteristic appearance
endoscopically, described as a salmon
or pink color in contrast to the light gray
appearance of esophageal squamous
mucosa.
 It should be emphasized that histologic
examination of esophageal biopsy
samples is required to confirm the
diagnosis of BE.
Dr. Ihab Samy 2013

5.  The sensitivity of white-light endoscopy
alone for the detection and diagnosis of
BE ranges from 80% to 90%.
 During endoscopy, special attention and
targeted biopsies should be focused on
lesions such as nodules, ulcers, and
other mucosal irregularities because
these lesions are more likely to
demonstrate dysplasia or cancer.
Dr. Ihab Samy 2013

6. Surveillance of NDBE
 Consider no surveillance.
 If surveillance is elected, perform EGD
every 3 to 5 years with 4-quadrant
biopsies every 2 cm.
 Consider endoscopic ablation (RFA) in
select cases (family history of EAC).
Dr. Ihab Samy 2013

7. Surveillance of IGD
 Clarify presence and grade of dysplasia
with expert GI pathologist.
 Increase antisecretory therapy to
eliminate esophageal inflammation.
 Repeat EGD and biopsy to clarify
dysplasia status.
Dr. Ihab Samy 2013

8. Surveillance of LGD
 Confirm with expert GI pathologist.
 Repeat EGD in 6 months to confirm LGD.
 Surveillance EGD every year, 4-quadrant
biopsies every 1 to 2 cm.
 Consider endoscopic resection or ablation.
Dr. Ihab Samy 2013

9. Surveillance of HGD
 Confirm with expert GI pathologist.
 Consider surveillance EGD every 3 months in select
patients, 4-quadrant biopsies every 1 cm.
 Consider endoscopic resection or RFA ablation.
 Consider EUS for local staging and
lymphadenopathy.
 Consider surgical consultation.
Dr. Ihab Samy 2013

10. Endoscopic management of BE with dysplasia
 Endoscopic therapy can be divided into
therapies that ablate dysplastic mucosa and
techniques that resect dysplastic mucosa.
 A key element of the endoscopic therapy of
dysplasia is that re-epithelialization of
squamous mucosa can only be achieved in
an acid-suppressed environment.
 Thus, the use of antisecretory agents or
antireflux surgery is a necessary adjunct to
these techniques.
Dr. Ihab Samy 2013

11. Endoscopic ablation
 Photodynamic therapy (PDT) using 5-aminolevulinic
acid or porfimer sodium as photosensitizing agents
has been used effectively to eliminate HGD (77%
over 5 years) and early EAC.
 Disadvantages of this technique include the inability
to eliminate NDBE, skin photosensitivity for as long
as 1 month, and stricture formation rates of
approximately 30%.
 PDT has been less commonly used for dysplasia
since the emergence of RFA.
Dr. Ihab Samy 2013

12.  RFA involves direct application of
radiofrequency energy to the esophageal
mucosa.
 Chest pain or discomfort is fairly common after
RFA treatment, but generally subsides after 1
week.
 GI hemorrhage and esophageal stricture
formation were also recorded.
 Surveillance every 3 months for the first year
after ablation, every 6 months for the next year,
and then annually.
Dr. Ihab Samy 2013

13.  Cryotherapy is an ablative technique that
causes cellular destruction by using freeze-
thaw cycles.
 During endoscopy, a spray catheter is
passed through the working channel of the
endoscope and either liquid nitrogen or
carbon dioxide is applied to the dysplastic
area.
 Significant Complications are uncommon
with this technique, but 1 case of perforation
has been reported.
Dr. Ihab Samy 2013

14. EMR / Endoscopic Submucosal Dissection
 Techniques designed to remove
targeted superficial tissue of the GI tract
(EMR) or large en bloc strips of mucosa
(ESD)
 A distinct advantage of EMR/ESD over
ablative therapy is the availability of
large tissue specimens for pathologic
examination and cancer staging.
Dr. Ihab Samy 2013

15.  EMR is indicated for shorter segment
dysplastic BE, nodular dysplasia, superficial
(T1a) EAC, and esophageal squamous cell
carcinoma (ESC).
 ESD can be used in similar situations and
may be preferred for extensive areas of
dysplasia or IMC.
Dr. Ihab Samy 2013

16. RECOMMENDATIONS of ASGE 2012
1. endoscopic screening for BE can be considered in select patients with multiple risk factors for BE and EAC, but patients should be informed that there is
insufficient evidence to affirm that this practice prevents cancer or prolongs life. QOEOEOE
2. no further endoscopic screening for BE after a screening examination with negative findings.
3. No surveillance EGD 1 year after the initial diagnosis of NDBE.
4. if patients with NDBE are enrolled in an EGD surveillance program, a surveillance EGD should be performed no more frequently than every 3
to 5 years, with white-light endoscopy and targeted plus 4-quadrant biopsies at every 2 cm of suspected BE.
5. only patients with BE who are candidates for therapy if dysplasia is identified be enrolled in EGD surveillance programs.
6. patients with a diagnosis of BE IGD undergo additional evaluation to clarify the diagnosis. This may include additional pathology review, dose escalation of
antisecretory therapy to eliminate confounding esophageal inflammation, and/or a repeat EGD and biopsy.
7. an expert GI pathologist should confirm the diagnosis of LGD and/or HGD.
8. patients with LGD undergo a repeat endoscopy within 6 months to confirm the diagnosis, then annual surveillance endoscopy using a standard biopsy protocol.
9. ablation should be considered in select patients with LGD. Appropriate surveillance intervals after ablation are unknown.
10. endoscopic resection of nodular dysplastic BE be performed to determine the stage of dysplasia before considering other ablative endoscopic therapy.
11. local staging with EUS FNA is an option in select patients being considered for endoscopic ablative therapy.
12. eradication with endoscopic resection or RFA should be considered for flat HGD in select cases because of its superior efficacy (compared with
surveillance) and side effect profile (compared with esophagectomy).
13. NO routine endoscopic surveillance in achalasia.
14. NO endoscopic routine screening in patients with aerodigestive cancer.
15. screening for esophageal carcinoma begin at age 30 in patients with tylosis. Surveillance intervals should be every 1 to 3 years.
16. screening for esophageal carcinoma begin approximately 10 to 20 years after caustic injury and performed every 2 to 3 years.
Dr. Ihab Samy 2013

17. Esophageal Carcinoma
 Malignancies of the esophagus are diagnosed via upper
endoscopy with mucosal biopsies.
 The sensitivity for mucosal biopsies to detect esophageal
carcinoma reaches 96% when multiple samples are obtained.
 Strictures may prevent complete visualization and sampling of
the obstructing malignancy.
 In these instances, brush cytology can improve the diagnostic
accuracy by 20%.
 Transoral or transnasal ultrathin endoscopes also may be used
for obstructing malignancies to visualize the extent and length of
the tumor.
Dr. Ihab Samy 2013

18. Staging of esophageal malignancies
 Staging of esophageal cancer has
traditionally involved EUS and FNA in
conjunction with cross-sectional imaging.
 Numerous studies have demonstrated the
superiority of EUS in both local tumor (T)
and nodal (N) staging over CT.
 Accuracy for T staging approaches 90% in
superficial and partially obstructing
esophageal cancers.
Dr. Ihab Samy 2013

19.  Dilation of malignant strictures to
facilitate echoendoscope passage for
EUS staging reported high complication
rates.
 Ultrathin US probes or wire-guided
instruments may be passed through the
working channel of an upper endoscope
for endosonography  limited
visualization of lymph node regions.
Dr. Ihab Samy 2013

20.  Endosonographic characteristics of
malignant lymph nodes include:
1. Size >10 mm,
2. Round and smooth features,
3. Proximity to the primary tumor
4. Hypoechogenicity.
 The accuracy of EUS for nodal staging
based solely on these acoustic criteria
approaches 80%.
Dr. Ihab Samy 2013

21. EUS guided FNA
 FNA of lymph nodes increases nodal
staging accuracy to 92%-98%.
 Tissue sampling contamination may
occur when the endoscope traverses the
tumor  False +ve results.
Dr. Ihab Samy 2013

22. EUS after neoadjuvant chemoradiation
 Fluorodeoxyglucose positron emission
tomography/CT appears to have better
accuracy than EUS or CT to detect
response to neoadjuvant chemoradiation.
 The accuracy of EUS in this clinical
situation may be weakened because
radiation induced mucosal inflammation of
the esophageal wall may not always be
distinguishable from residual disease.
Dr. Ihab Samy 2013

23. Endoscopic therapy for esophageal cancer
 Therapy with curative intent.
 Therapy to palliate symptoms.
Dr. Ihab Samy 2013

24.  Distinguishing mucosal from submucosal
invasion is an important factor that contributes
to the success of endoscopic curative therapies.
 Stage T1a malignancies include lesions
confined to the mucosa: M1 (intraepithelial), M2
(lamina propria invasion), or M3 (muscularis
mucosa invasion).
 Submucosal or T1b malignancies are classified
into Sm1 (superficial submucosa invasion), Sm2
(invasion to center of submucosa), or Sm3
(invasion to deep submucosa).
Dr. Ihab Samy 2013

25.  Mucosal (T1a) malignancies have extremely low
risk of local lymph node progression while
submucosal invasion (T1b) markedly increases
the risk of lymph node metastases. Metastatic
disease is present in up to 21% of Sm1 and
56% of Sm3 cancers.
 In addition, early cancers with features of
lymphovascular invasion on histology or poorly
differentiated cancers are generally considered
to represent a higher risk for metastatic disease.
 These factors emphasize the need for accurate
staging via EUS or en bloc tissue sampling.
Dr. Ihab Samy 2013

26.  Either resection or ablation techniques.
 A distinct advantage of resection over
ablation therapy is the availability of
large tissue specimens for pathologic
diagnosis and accurate cancer staging.
Dr. Ihab Samy 2013

27. Resection
 EMR and endoscopic submucosal dissection (ESD)
are endoscopic techniques that permit targeted
removal of superficial tissue of the GI tract.
 EMR is indicated for nodular BE and T1a lesions and
may be used for flat BE with high-grade dysplasia.
 ESD can be used in similar situations but is preferred
to EMR for large areas of dysplasia (2 cm) or T1b
malignancies (ie, confined to the submucosa).
Dr. Ihab Samy 2013

28.  EMR successfully eradicates 91% to 98% of T1a
cancers.
 Potential complications of EMR are:
1. Bleeding (Delayed bleeding is rare).Immediate,
postresection bleeding can occur in 10% of
patients.
2. Perforation (less than 3%.)
3. Stricture formation (depending on the
circumference and length of mucosa removed by
EMR, but can occur in up to 37%  successfully
managed by endoscopic dilation).
Dr. Ihab Samy 2013

29.  Reports from Japan of ESD for SCC of the
esophagus show up to 100% en bloc
resection rates and 80% curative resection
rates.
 A retrospective review of ESD versus EMR
for the treatment of early SCC, reported
higher en bloc resection and lower local
recurrence rates with ESD.
 ESD in the esophagus has been associated
with perforation rates of 2% to 5% and
stricture rates between 5% and 17.2%
Dr. Ihab Samy 2013

30. Ablation
1. Photodynamic therapy (PDT)
2. Cryotherapy
3. Argon plasma coagulation (APC)
4. Heater probe treatment
5. Radiofrequency ablation (RFA)
 These techniques may be used alone or in
combination with mucosal resection
techniques, depending on the clinical
scenario.
Dr. Ihab Samy 2013

31.  Patients treated with endoscopic methods
had similar median cancer-free survival
compared with those treated with surgery.
 Equivalent survival at 3 years in patients with
high grade dysplasia and intramucosal
carcinoma treated with endoscopic resection
and ablation compared with surgical
resection.
 Morbidity associated with endoscopic
treatment was significantly lower than with
surgery.
Dr. Ihab Samy 2013

32. Endoscopic palliative therapy
 Endoscopic options for palliation
include:
1. Dilation.
2. Stenting.
3. Chemical or Laser debulking.
4. Enteral feeding.
Dr. Ihab Samy 2013

33.  Dilation of obstructing esophageal masses
rarely provides sustained relief of symptoms
and is complicated by a high perforation rate.
 More durable symptom relief can be obtained
by esophageal stenting.
 Self-expandable metal stents (SEMS) have
been used since the 1990s to palliate
malignancies.
 An overall improvement in quality of life in
patients treated with stents was noted.
Dr. Ihab Samy 2013

34.  Stent complications include
1. Intolerable chest pain
2. Perforation
3. Migration
4. Tumor ingrowth
5. Bleeding
6. Fistula formation
Dr. Ihab Samy 2013

35.  A tracheoesophageal fistula can develop
from tumor penetration or as a complication
of radiation therapy.
 SEMS can be used to palliate malignant
tracheoesophageal fistulae by sealing the
esophagus from the airway and preventing
aspiration of luminal contents.
 Successful closure of tracheoesophageal
fistulae has been reported in up to 86% of
patients with SEMS placement.
Dr. Ihab Samy 2013

36.  Successful restoration of luminal patency by using
laser ablation (Nd:YAG) has been reported in up to
97% of patients, but multiple sessions are required.
 Endoscopic placement of enteral feeding tubes (eg,
gastrostomy tube) bypasses obstructing lesions of
the upper GI tract in order to permit delivery of
nutrition.
 Gastrostomy tube placement can complicate
esophagectomy and gastric pull-up procedures.
 Malignant metastases at stoma sites have been
reported
Dr. Ihab Samy 2013

37. Evaluation and treatment of patients with
biliary neoplasia
 CT, magnetic resonance imaging (MRI), and magnetic resonance
cholangiography (MRC), are useful for confirming dilation of the biliary
and/or pancreatic ducts and staging more advanced disease but are
inferior to side-viewing endoscopy and EUS for detecting small
ampullary lesions.
 Duodenoscopy by using a side-viewing endoscope permits direct
visualization of the ampulla and tissue acquisition and EUS permits
diagnosis as well as staging via FNA tissue sampling
 EUS and intraductal US (IDUS) can assess the depth of invasion in
relation to the muscularis propria as well as intraductal extension and
periampullary nodal involvement, facilitating selection of patients who
can undergo surgical ampullectomy instead of
pancreaticoduodenectomy.
 Although not endorsed for routine clinical management, endoscopic
ampullectomy has been described for the removal of early ampullary
adenocarcinomas.
Dr. Ihab Samy 2013

38. ERCP
 ERCP is important in the diagnosis and
management of cholangiocarcinoma
because tissue confirmation can be
achieved with this technique.
 Brushings for cytology and biopsy
samples for histology can confirm the
diagnosis of cholangiocarcinoma.
Dr. Ihab Samy 2013

39.  If the level of obstruction is located below the
level of the bifurcation (Bismuth type I
lesions), surgical resection should be
considered in medically stable patients
without metastatic disease.
 If the patient is a poor surgical candidate,
palliation with plastic or metal stents should
be considered.
Dr. Ihab Samy 2013

40. Bismuth classification of cholangiocarcinoma
Dr. Ihab Samy 2013

41.  If the level of obstruction is at or above the
hilum, Unilateral endoscopic biliary stent
placement directed by prior imaging has
been shown to achieve palliation of jaundice
equal to that of bilateral stent placement, but
with a lower risk of cholangitis and lower
cost.
 In patients in whom ERCP is unsuccessful,
interventional EUS techniques or
percutaneous transhepatic cholangiography
with stent placement can be considered
where expertise is available.
Dr. Ihab Samy 2013

42. Biliary stents
 Biliary stents are made of plastic or metal.
 Plastic stents are less expensive, but they occlude
by a median of 3 to 6 months because of the
deposition of bacterial biofilm.
 Self-expandable metal stents may remain patent
longer than plastic stents.
 Although it has been suggested that the use of self
expandable metal stents be reserved for patients
whose estimated survival is longer than 3 to 6
months the choice of stent type should be
individualized.
Dr. Ihab Samy 2013

43. RECOMMENDATIONS of ASGE 2012
1. EUS should be performed in patients with suspected ampullary adenocarcinoma or
cholangiocarcinoma if the EUS findings or positive FNA results would change
management.
2. MRC to assess for resectability if a CT scan suggests cholangiocarcinoma,
particularly of the bifurcation. If the lesion is unresectable, endoscopic palliation of
jaundice should be performed by using MRC as a guide for unilateral drainage to
minimize the risk of cholangitis.
3. ERCP to obtain tissue or facilitate further evaluation of indeterminate strictures.
4. Symptomatic patients with GBP undergo cholecystectomy.
5. Asymptomatic patients with a GBP larger than 10 mm undergo cholecystectomy.
6. Asymptomatic patients with a GBP 6 mm to 10 mm in size and without other risk
factors for GB cancer (60 years of age and older, coexistence of gallstones, sessile
morphology) be followed by TUS every 12 months.
7. The presence of any GBP should prompt cholecystectomy in patients with PSC.
Dr. Ihab Samy 2013

44. Gastric epithelial polyps
 The majority of gastric epithelial polyps found during
endoscopy are incidental and frequently either of
hyperplastic or fundic gland histology (70%-90%).
 Fundic gland polyps may develop in association with
long-term proton pump inhibitor use but have not
been associated with an increased risk of cancer.
 Adenomatous polyps have malignant potential, and
this risk correlates with size and older patient age.
Dr. Ihab Samy 2013

45.  Patients with adenomatous polyps should
have complete excision and surveillance
endoscopy to ensure no recurrence.
 Polyp histology cannot be reliably
distinguished by endoscopic appearance,
and therefore either biopsy or polypectomy is
warranted in any suspicious lesion.
 Hyperplastic polyps may have an increased
risk of cancer (dysplastic elements being
present in up to 19% of hyperplastic polyps)
Dr. Ihab Samy 2013

46.  Polypoid defects of any size detected radiographically
should be evaluated endoscopically, with biopsy and/or
removal of the lesions.
 If endoscopic polypectomy is not possible, a biopsy of the
polyp should be performed, and if adenomatous or
dysplastic tissue is detected, referral for surgical resection
should be considered.
 If representative biopsy samples are obtained and the
polyp is nondysplastic, no further intervention is necessary.
 If it is felt that endoscopic biopsy cannot sufficiently
exclude the presence of dysplastic elements, referral for
surgical resection is reasonable in polyps that cannot be
removed endoscopically.
Dr. Ihab Samy 2013

47.  Surveillance endoscopy 1 year after removing
adenomatous gastric polyps is reasonable to assess
recurrence at the prior excision site, new or previously
missed polyps, and/or supervening early carcinoma.
 If the results of this examination are negative, repeat
surveillance endoscopy should be repeated no more
frequently than at 3- to 5-year intervals.
 Follow-up after resection of polyps with high-grade
dysplasia and early gastric cancer should be
individualized.
 No surveillance endoscopy is necessary after adequate
sampling or removal of nondysplastic gastric polyps.
Dr. Ihab Samy 2013

48. Gastric intestinal metaplasia and dysplasia
 Gastric intestinal metaplasia (IM) is
recognized as a premalignant condition
that may be the result of an adaptive
response to environmental stimuli such as
H pylori infection, smoking, and high salt
intake.
 Patients with IM may have a 10-fold
increased risk of developing gastric cancer,
which may be highest in certain
geographical areas (e.g, Japan) and in
patients infected with H pylori.
Dr. Ihab Samy 2013

49.  Endoscopic surveillance for gastric intestinal
metaplasia has not been extensively studied and
therefore cannot be uniformly recommended.
 Patients at increased risk for gastric cancer due to
ethnic background or family history may benefit
from surveillance.
 Endoscopic surveillance should incorporate a
topographic mapping of the entire stomach.
 Patients with confirmed high-grade dysplasia are at
significant risk for progressing to cancer and should
be considered for gastrectomy or local (eg,
endoscopic) resection.
Dr. Ihab Samy 2013

50. FAMILIAL ADENOMATOUS POLYPOSIS AND HEREDITARY NONPOLYPOSIS
COLORECTAL CANCER
 Patients with FAP should undergo upper endoscopy
early in the third decade of life.
 If no adenomas are detected, another exam should
be performed in 5 years because adenomatous
change may occur later in the course of the disease.
 For patients with duodenal and periampullary
adenomas, surveillance endoscopy and biopsy
should be performed at intervals every 6 months for
a minimum of 2 years, with endoscopy thereafter at
3-year intervals.
Dr. Ihab Samy 2013

51.  Biopsies of gastric polyps in patients with FAP
may be performed to confirm that they are
fundic gland polyps and to assess for dysplasia.
 Antral polyps are usually adenomas and should
be resected.
 Patients with HNPCC are at increased risk for
the development of gastric and small-bowel
cancer.
 Although there is insufficient data to show a
benefit for upper endoscopic surveillance in
patients with HNPCC, endoscopic surveillance
should be considered.
Dr. Ihab Samy 2013

52. Colorectal Cancer (CRC)
 During the past decade, great emphasis
has been placed on the use of colonoscopy
for the early detection and the removal of
adenomatous polyps to reduce the
incidence and the mortality of CRC.
 Once CRC has developed, colonoscopy
also has an important role in the diagnosis
and subsequent disease management.
Dr. Ihab Samy 2013

53.  In general, polypoid lesions found at the time of
colonoscopy should be removed.
 Colonic lesions not amenable to endoscopic
resection can be sampled with biopsy forceps.
 Biopsy specimens of broad sessile lesions or of
large mass lesions should be obtained from
different areas, including the edges and the center
of the lesion, if possible.
 The addition of cytology brushings to forceps
biopsies may increase the diagnostic yield,
especially in the setting of obstructing tumors that
cannot be traversed.
Dr. Ihab Samy 2013

54.  There was no additional diagnostic yield from
obtaining more than 6 biopsy specimens.
 In cases where endoscopic biopsy
specimens are nondiagnostic and cancer is
highly suspected, clinicians should consider
obtaining a second opinion from an expert
pathologist and/or performing repeat
colonoscopy for additional tissue sampling.
 Surgery is indicated for suspicious lesions
with nondiagnostic biopsy specimens.
Dr. Ihab Samy 2013

55.  EMR can be selectively used in the removal of
colonic lesions that may potentially be
malignant or may have high-grade dysplasia
(HGD).
 The use of submucosal solution injection, which
allows for the complete resection of the mucosa
through the mid to deep submucosa.
 EUS also can serve as a useful tool in the
evaluation of colonic lesions before EMR by
determining depth of invasion and by detecting
the presence of lymph nodes that may indicate
malignancy.
Dr. Ihab Samy 2013

56. Localization
 colonoscopy has an important role in the
localization of malignant lesions for subsequent
identification at the time of surgery.
 Preoperative endoscopic marking can be helpful in
localizing flat, small, colonic lesions that may be
difficult to identify by inspection or palpation during
surgery.
 Marking techniques currently available include
endoscopic tattooing and metallic clip placement.
Dr. Ihab Samy 2013

57. Staging
 The accuracy of EUS for T staging ranges from 80% to
95%.
 EUS has been demonstrated to be superior to CT in
determining the T stage of rectal cancer.
 Magnetic resonance imaging with endorectal coils has
been compared with EUS , appears to have similar
accuracy for T staging except in differentiating between T1
and T2 tumors, where EUS may be superior.
 Abdominal CT, in combination with EUS, appears to be the
most cost-effective strategy in staging rectal cancer
Dr. Ihab Samy 2013

58.  EUS-guided FNA of perirectal lymph nodes may
be most helpful in the setting of T1 or T2
disease in which the presence of malignant
perirectal lymph nodes would change patient
management to include preoperative
chemoradiation therapy.
 Malignant strictures in the rectum that are not
traversable may be difficult to evaluate by EUS.
 The use of miniprobes advanced through the
endoscope channel or rigid rectal EUS probes
may be helpful in these cases.
Dr. Ihab Samy 2013

59. Detection of Recurrence
 EUS and EUS-guided FNA are highly sensitive
methods for the detection and the diagnosis of
regional recurrence.
 Tumor recurrence often may present extraluminally
and can be missed by routine surveillance with
digital rectal examination and colonoscopy.
 The early detection of local cancer recurrence may
lead to potentially curative surgical re-excision.
Dr. Ihab Samy 2013

60. Endoscopic management of malignant
colonic obstruction
 Malignant obstruction of the colon can
occur in 8% to 30% of patients with
colorectal cancer.
 Endoscopic management of malignant
obstruction with laser therapy or stent
placement offers a safe and an effective
alternative to surgery.
Dr. Ihab Samy 2013

61.  Currently, there are two main indications for
the endoscopic management of colonic
obstruction:
1. Temporary colonic decompression as a
bridge to surgery.
2. Palliation of patients who are deemed poor
surgical candidates or who have incurable
disease.
Dr. Ihab Samy 2013

62.  Successful endoscopic decompression of
acute obstruction allows for the stabilization
of the patient and for evaluation of the
patient’s extent of disease and comorbid
illnesses before surgery.
 In operative candidates, acute
decompression avoids the need for a
diverting colostomy and a second surgery for
reanastomosis, because the tumor can be
resected during a one-stage procedure after
adequate bowel preparation.
Dr. Ihab Samy 2013

63.  Laser therapy has a high success rate in the
treatment of malignant colonic obstruction
ranging from 80% to 90%.
 The placement of self-expandable metal
stents (SEMS) has recently evolved into a
more widely used method of endoscopic
colonic decompression.
 The success rate of stent deployment and
the relief of malignant colonic obstruction has
been reported to range from 70% to 95%.
Dr. Ihab Samy 2013

64.  SEMS placement offers a significant
cost benefit in the management of
malignant colonic obstruction by
avoiding diverting colostomy and a two-
stage operation in surgical candidates.
 Dilation of the malignant stricture does
not appear to be necessary before
SEMS placement and may be
associated with a higher risk of
perforation.
Dr. Ihab Samy 2013

65.  Treatment with chemotherapy and radiation
therapy after SEMS placement may be
associated with an increased risk of
complications.
 Stent obstruction can occur because of stool
impaction, tumor ingrowth, or tumor overgrowth,
which all require endoscopic intervention.
 Patients should be advised to follow a low
residue diet and to take laxatives, stool
softeners, or mineral oil supplements to avoid
stool impaction after SEMS placement.
Dr. Ihab Samy 2013

66. Endoscopic management of malignant colonic
polyps and polyps with HGD
 Invasive carcinoma may be found in
approximately 2% to 4% of colonic polyps
removed endoscopically.
 Polypectomy or EMR may be curative in
selected, superficially invasive colon cancers.
 A malignant polyp is defined as one containing
invasive carcinoma penetrating through the
muscularis mucosa into the submucosa.
Dr. Ihab Samy 2013

67.  The rate of lymph node metastasis is
significantly associated with the depth of tumor
invasion within the submucosa, with tumors
invading the upper third, middle third, and lower
third of the submucosa, having 2%, 9%, and
35% rates of lymph node metastasis,
respectively.
 Pedunculated polyps with cancer confined to
the submucosa and without evidence of
unfavorable histologic factors have a 0.3% risk
of cancer recurrence or lymph-node metastasis
after complete endoscopic removal, whereas
similar sessile polyps have a 4.8% risk.
Dr. Ihab Samy 2013

68.  Unfavorable histopathologic factors of malignant
colonic polyps associated with high risk of lymph-
node metastases and local cancer recurrence after
endoscopic resection:
1. Poorly differentiated histology
2. Vascular invasion
3. Lymphatic invasion
4. Cancer involvement of the resection margin
5. Incomplete endoscopic resection
Dr. Ihab Samy 2013

69.  Pedunculated polyps confined to the
submucosa, with no evidence of unfavorable
histologic features, can be definitively treated
with endoscopic resection, without the need
for surgical resection.
 In cases of pedunculated polyps harboring
unfavorable histologic features,
demonstrating cancer within the resection
margin, or extending through the submucosa
into the deeper wall layers, surgery is
recommended.
Dr. Ihab Samy 2013

70.  Malignant sessile polyps confined to the
submucosa and demonstrating no evidence of
unfavorable histologic factors have a small
increased risk of lymph-node metastasis and
local recurrence compared with similar
pedunculated polyps after endoscopic
resection.
 Endoscopic resection of this subset of sessile
polyps may be adequate if the resection was
complete and en bloc.
 However, surgical resection should be
considered to ensure definitive treatment.
Dr. Ihab Samy 2013

71.  The finding of a malignant polyp in patients with
ulcerative colitis or Crohn’s colitis should be
considered an indication for total colectomy.
 Endoscopic resection of malignant polyps with
unfavorable histologic features or piecemeal
resection of large malignant polyps can be
considered in patients deemed poor surgical
candidates because of comorbid illnesses.
 Surveillance after the endoscopic removal of a
malignant polyp should consist of a follow-up
colonoscopy within 3 to 6 months after resection.
Dr. Ihab Samy 2013

72.  Polypectomy or EMR also can be used as the
primary management of polypoid lesions with
HGD.
 Previously known as carcinoma in situ or
intramucosal cancer, HGD currently is defined
as dysplastic neoplastic tissue confined within
the mucosal wall layers without invasion of the
submucosa.
 Endoscopic removal of lesions with HGD is
adequate, provided that the endoscopist is
confident in the completeness of resection.
Dr. Ihab Samy 2013

73.  Surveillance after the endoscopic resection of a
lesion with HGD should consist of repeat
colonoscopy in 3 years.
 If residual tissue is identified, this should be
removed and a second follow-up examination
should be performed within 3 to 6 months to
verify complete resection.
 If a polyp cannot be removed completely within
1 to 3 examinations, surgery is recommended.
Dr. Ihab Samy 2013

74. Capsule endoscopy (CE)
 After the Food and Drug Administration
(FDA) approval in 2001, small bowel
capsule endoscopy has rapidly gained
ground in the armamentarium of small
bowel investigation techniques.
 Small bowel endoscopy has proved to be
an extremely efficient tool providing high
quality images of the entire small bowel
which were largely inaccessible to flexible
endoscopy.
Dr. Ihab Samy 2013

75.  CE is a very sensitive diagnostic technique to
detect small bowel pathology.
 It has a higher diagnostic yield than
conventional diagnostic methods, i.e., push
enteroscopy, small-bowel follow-through,
conventional CT and angiography.
 In 15%-20% of all CE’s the capsule does not
reach the cecum within recording time.
 Risk factors for incomplete CE procedures
include previous small-bowel surgery,
hospitalization, moderate or poor bowel
cleansing, and a gastric transit time longer
than 45 min.
Dr. Ihab Samy 2013

76. Dr. Ihab Samy 2013

77.  For a good and complete evaluation of the
small bowel, the capsule should reach the
cecum within the recording time, which is eight
to eleven hours depending on the
manufacturer.
 Therefore, some investigators use a prokinetic
agent to speed up the gastric and small bowel
transit.
 However, the short bowel transit time (SBTT)
may influence the diagnostic yield of CE.
Dr. Ihab Samy 2013

78. Dr. Ihab Samy 2013

79. Colon capsule endoscopy
 In 2006, Given Imaging Ltd. developed the
first generation of capsule specifically
designed for colon investigation.
 Non-invasive techniques for colonoscopy,
such as CT colonography and colon
capsule endoscopy are currently being
evaluated as alternatives to conventional
colonoscopy in order to improve
compliance to screening programs.
Dr. Ihab Samy 2013

80.  PCCE was able to visualize the entire colon in
80% of cases.
 The level of bowel preparation was quite high,
being rated as good-excellent in 84% of the
cases.
 PCCE may be indicated when a patient refuses
conventional colonoscopy or when colonoscopy
provides inconclusive results or when the risks
from colonoscopy, such as colon perforation (for
example when there is a clinical suspicion of
acute diverticulitis), may outweigh the benefits.
Dr. Ihab Samy 2013

81.  Bowel preparation is the most
challenging factor in PCCE
implementation.
 A reasonable balance between
adequate preparation and patient
satisfaction needs to be pursued, and
the adoption of a split regimen of PEG is
a step in this direction.
Dr. Ihab Samy 2013

82. Day Time Action
−5 to −2 All day Low fibre diet
−2 08:00 pm 4 senna tablets
(48mg)
−1 All day Liquid diet only
7:00 pm–9:00 pm 2 L PEG
Exam day 6:00 am–8:00 am 2 L PEG
8:45 am Domperidone (20 mg)
9:00 am PillCam ingestion
11:00 am 30 mL NaP + 1 L water
02:00 pm 15 mL NaP + ½ L
water
04:00 pm 10 mg Bisacodyl
(suppository)
07:00 pm Colonoscopy
Dr. Ihab Samy 2013

83. Thank you
Dr. Ihab Samy 2013