Gastroenterology - Endoscopic Submucosal Dissection

Introduction

This leaflet aims to provide you with information regarding an endoscopic submucosal dissection (ESD) for patients with abnormal tissue or lesions in their bowel, who are undergoing treatment at Oldham hospital. It is important that you are fully aware of the benefits and risks of this procedure before you sign the consent form.

What is an Endoscopic Submucosal Dissection (ESD)?

Endoscopic submucosal dissection is a procedure which is already being used in the UK and across the world, to remove lesions which are found in the bowel. We have been doing ESD and similar procedures in our Trust since 2010 onwards.

Abnormalities or lesions in the bowel can be cancerous or have a high risk of becoming cancerous, or they can be harmless (benign).

Treatment usually involves removing the lesion. This can be done either via a surgical operation or via a camera which is inserted through the anus to view the abnormal area.

In endoscopic submucosal dissection (ESD) the abnormal area or polyp lesion is removed, along with a small area of normal tissue surrounding the lesion. When the lesion or polyp has been located, it is raised by injecting fluid into the tissue underneath (picture A overleaf). The injection lifts the polyp away from the bowel wall muscle layers, making it easier and safter to remove using diathermy (heated knives) (picture B overleaf). You will not feel this.

If this area, when looked at under the microscope, is found to be clear of abnormal cells, this is called a clear margin and reduces the risk of recurrence in the same area.

You will find some more detailed information about the potential benefits of the procedure, the procedure itself and the risks and alternatives in this leaflet. Please do ask our team if there is anything which is not clear or which you would like more information about.

What is a colonic lesion?

In some people, changes occur in the cells lining the colon. These can form lesions or polyps where there are many abnormal cells. In time, in some of these lesions in some people, the cells can change more and become pre-cancerous or cancerous.

When doctors perform a procedure called a colonoscopy, where a camera is inserted into your bowel or colon through your anus, they can see these lesions. By examining them carefully through the endoscope, the doctors are often able to tell which of these lesions need removal as they are pre-cancerous or cancerous lesions.

What are the potential benefits of removing colonic lesions?

The aim is then to remove these cells or lesions to stop them spreading elsewhere in the body. It is best to remove the cells with some normal cells around them (what is called a resection margin) as this reduces the risk of the lesion coming back or spreading elsewhere. If this is done it is called a clear resection margin.

The lesion is then sent to the histopathology laboratory where a team of doctors look at it under the microscope. If it is all in one piece, rather than several small pieces it is called an en bloc resection (lateral margin and deep margin clearance). This makes it easier to examine and tells more about the lesion to let the doctors and you understand the chance of it coming back.

Who is suitable for the procedure?

Patients being considered for endoscopic submucosal dissection (ESD) will have had a colonoscopy either at Rochdale Infirmary, Fairfield General or Royal Oldham or at another hospital, which has found a lesion that would be most suitable to be removed by ESD.

The doctor or nurse performing this initial procedure will take photos and sometimes a small biopsy of the lesion. These will then be discussed among us and possibly at an MDT (multidisciplinary team) meeting where they will review the photographs and the biopsies (if taken) to decide if an ESD will be the best procedure for you.

You will then meet one of the doctors, who will perform the ESD procedure, in clinic to discuss more about the procedure.
Alternatively, you would have a telephone consultation to discuss the plan. However, at times we may have to convert a planned endoscopic mucosal resection (EMR) to a submucosal dissection or a hybrid of above procedures (cut around the lesion followed by part dissection to remove using snares).

What does the procedure involve?

An endoscope is a tube with a camera on the tip that is designed to look at, and perform procedures within, the digestive system.

During the procedure you will first be given some sedation through a cannula in your arm. Although this is not a full general anaesthetic it will make you a little bit sleepy and relaxed. The endoscope (with some lubricating jelly) is then passed from your anus or bottom into your large bowel or colon. The lesion which has been previously seen will then be looked for by the doctor performing the procedure.

When they have found it they will again look at the lesion to make sure that it is suitable to be removed by ESD. The doctor will then use a needle that is inserted through the endoscope to inject some fluid around the lesion. This helps separate the abnormal tissue from the normal tissue around it.

A very small knife, which has the ability to pass electricity through it, is then placed through the endoscope. The electricity is then used to cut around the lesion. The knife is then used to separate out the abnormal area from the normal area and remove the abnormal cells or lesion. This is done quite slowly, and the device can also be used to stop any bleeding while the procedure is ongoing. You should not feel any pain or discomfort from the knife due to the way the nerves supplying that area are able to sense the cutting. The abnormal lesion is then carried out from the bowel with the endoscope and sent to the laboratory to be looked at under the microscope.
 
Sometimes very small clips are also used after the procedure to stop any extra bleeding or to hold together some of the normal tissue. These will fall off naturally in time and be passed in your bowel movements. As they are so small it is unlikely you will be able to see them when they pass through.

How long will the procedure take?

How long the procedure takes is quite variable. It will depend on the size of the abnormal lesion and where it is located in your bowel. Usually, this procedure will take 1 to 4 hours, however in some cases the procedure may be even longer. The doctor who sees you in clinic may be able to give you some idea.

What is the risk of the procedure?

It is very important that you are fully aware of the benefits and risks of having the endoscopic submucosal dissection. All procedures that are carried out with an endoscopy carrying some degree of risk:

• Approximately 1 in 50 patients are at risk of bleeding during the procedure which can usually be treated during the procedure
• Approximately 1 in 50 patients are at risk of something called a perforation, where a small tear is formed during the cutting to separate the lesion. These can usually be treated at the time of the procedure
• Approximately 1 in 50 patients are at risk of the procedure not being able to be completed, which may then need removal of the lesion either by a different endoscopic technique or by surgery

Any of these could require a longer stay in hospital and a longer recovery period and potentially an operation or further procedure. There is also a small risk of death related to complications or from your pre-existing medical conditions. We would also recommend that long distance and foreign travel is best avoided for a fortnight after as there is a small risk of late bleeding. Your doctor or a member of the team will discuss the risks, benefits, possible complications and expected outcomes of the procedure with you. The exact risks will be different for each person.

What happens if I choose not to have the procedure?

There are other treatment options available.

These include:

• Surgical operations to remove the bowel where the lesion is located
• Attempts to remove the lesion by other endoscopic methods (including something called endoscopic mucosal resection or hybrid of above procedures)
• Doing nothing

However, these interventions may not be suitable for you. If you have any questions about these other treatment options, please discuss this with the team.

What will happen before the procedure?

As mentioned above, you will be seen in the clinic or have a telephone consultation to discuss any questions you may have about the procedure some time before the procedure.

On the day of the procedure, your doctor will go through a written consent form with you to confirm that you are happy to proceed with the procedure. Please remember that you can withdraw your consent at any time, should you wish.

What should I do about my medications?

If you are taking any medications at the time of the pre- assessment appointment, please bring them with you. You may need to stop some of your tablets before your procedure and you will be given advice on this.

Please remember to let us know if you are taking any blood thinning medications like Aspirin, Clopidogrel, Warfarin or Rivaroxaban. Please remember that you should also bring your medications with you when you come for the procedure.

What will happen before I come to hospital?

We will send you a letter confirming the date of your admission and details of where you should come to on the day of the procedure. Please try to remember the below points before coming in:

• Do not bring any valuables into hospital as we cannot be held responsible for any loss or damage
• Please remove all jewellery (except wedding rings)
• Please bring in some night clothes, day clothes and wash items
• Please have a contact number for the person who is going to take you home

What happens after the procedure?

You will be taken from the procedure room to the recovery area where you will be closely monitored. You will be connected to machines that monitor the activity of your heart. You will usually stay in the endoscopy recovery area for 1 or 2 hours. The exact time will be different for everybody.

You may be given oxygen until you are fully awake. This is given through a plastic tube which sits in your nostrils.

You may have a tube (drop giving you fluid into your vein) going into the back of your hand. This is removed once you are drinking enough fluid.

You will be encouraged to get out of bed and move around on the day of the procedure.

We may keep you in the hospital ward for one night after the procedure. Most times we may be able to let you go home on the same day as the procedure, but we will discuss this with you.

Some pain after your operation is normal. You will be given incremental doses of pain relief during the procedure and sedation as required. If you have pain please inform the nurse looking after you. You can then be given pain relief at regular intervals throughout the observation period.

You will be given a full copy of the report and the nurse will explain the report to you before your discharge.

What happens after I go home?

Most people go home the same day following the ESD. You should have someone to take you home after the procedure. Please let us know if this will be difficult for you. If you have a long journey home and are travelling by car, stop every hour or so and stretch your legs to prevent you becoming too uncomfortable.

Once you are at home you can go back to your normal activities. If you experience any of the following symptoms please contact us as soon as possible:

• A temperature or fever
• Severe abdominal pain
• A swollen or distended abdomen
• Severe or uncontrolled vomiting
• Blood when you go to the toilet (more than an egg cup full)

It is best not to compare your recovery with other people who have had the same procedure, we are all different and recover at different rates.

What is the follow-up like after the procedure?

You will be followed-up by the medical or surgical referring team to go through the results of the samples which were sent to the laboratory during your procedure. Depending on the results this will decide when you will need another colonoscopy to check the area where the lesion was.

Contact details

Direct line - Secretary 01706 517841
 

Royal Oldham Hospital Unit nursing contact - 0161 627 8513

Out of hours: Please call switchboard on 0161 624 0420 and ask to speak to the gastroenterology registrar on call or attend A & E at Royal Oldham Hospital with a copy of the procedure report.

Space to write any questions you may wish to ask: