Innovations in Endoluminal Surgery
Each year, more than 30,000 colon and rectal resections for non-cancerous lesions and polyps are performed nationwide. To meet the need for this growing trend of minimally invasive surgery, Amit Bhatt, MD, and Emre Gorgun, MD, established Cleveland Clinic's Endoluminal Surgery Center. Listen and learn about the innovative, multidisciplinary, and world-class procedures now taking place at Cleveland Clinic.
Innovations in Endoluminal Surgery
Scott Steele: Butts & Guts, a Cleveland clinic podcast exploring your digestive and surgical health from end to end.
So Hi again everybody, and welcome to another episode of Butts & Guts. I'm your host, Scott Steele, the Chairman of Colorectal Surgery here at Cleveland Clinic in beautiful Cleveland, Ohio. And today we're very excited to have Dr. Amit Bhatt and Dr. Emre Gorgun here. They're the Co-directors of the Endoluminal Surgery Center here at the Cleveland Clinic. Gentlemen, welcome to Butts & Guts.
Amit Bhatt: Good morning.
Emre Gorgun: Good morning and thanks for having us.
Scott Steele: So Amit, we'll start with you since Emre is a returning guest back from 2018, and we always like to start out with everybody telling a little bit about yourself. Where are you from? Where'd you train? And how did it come to the point that you're here at the Cleveland Clinic?
Amit Bhatt: Hey Scott, thanks for having us. So I was born in England, grew up around the world and came to Cleveland Clinic for my internal medicine residency, stayed for my GI fellowship, advanced endoscopy fellowship and ended up staying on as staff.
Scott Steele: And Emre, for those who haven't listened to the episode back then, tell us a little bit about yourself.
Emre Gorgun: Sure. Thanks again also for having us and being here second time is a true privilege. I was born in Istanbul, Turkey and raised there, did my medical school as well as residency, then moved down to the United States where I did repeat my residency training and fellowship. And then I've been on full faculty here at Cleveland Clinic, Colorectal Surgery since 2011.
Scott Steele: Well, we're very excited to have both of you on. And so for all of the listeners out there, I encourage you to go back and listen to some of the different podcasts, which can provide a little bit more robust information about what we're going to talk about today being endoluminal surgery.
But Emre, we'll start with you. So we've discussed surgical endoscopy with Dr. Ponsky on Butts & Guts in the past, but can you give a high-level overview just in first and foremost about what endoscopy is, what the type of procedures are included in that term and kind of why these procedures are needed?
Emre Gorgun: Surgical endoscopy is an evolving area in medicine and more and more we see the need for more minimally invasive and creating less morbidity for our patients. Rather than doing these major abdominal surgeries or open surgeries, there is a trend to be more minimally invasive. And towards that goal, flexible endoscopy fits extremely well. It allows us to use natural orifices if you will, like the mouth, or anus, or vagina for GYN areas, and then using these advanced, technologically advanced methods and tools do advanced procedures and I think that's what we're going to be talking next 15, 20 minutes or so today.
Scott Steele: So Amit, the goal with a lot of these things is to take out polyps and even early cancers, but what is the scope of how often this comes up and how would a patient know if they needed any sort of these procedures that you have or sometimes these things have no symptoms at all?
Emre Gorgun: Very good point, Scott. Just wanted to build on what Emre said is a sort of this is forefronts of endoluminal surgery is about doing things minimally invasive and operating through an endoscope to take out tumors or lesions that traditionally required surgery. The majority of lesions that we can take out and endoscopically, or through endoluminal surgery, or those with a low risk of going to lymph nodes.
So the major difference between endoscopic resection of a tumor and surgical resection of the tumor is absence of lymph node dissection or taking out the lymph nodes with endoscopic technique. And what that means is endoscopic resection should only be performed on tumors or lesions that have a low risk of going to lymph nodes. And those were generally the earliest cancers or precancerous lesions that we see. The majority of these lesions do not cause symptoms and they're either found on screening tests or serendipitously when somebody goes through an upper endoscopy, may be for abdominal pain or other symptoms and are found to have an early esophageal or gastric cancer.
Scott Steele: So I should make a note to the listeners that, to put this all in reference, there's about 30,000 colon and rectal resections just for the lower polyps alone for noncancerous lesions. And gentlemen, obviously we have both of you on here because Amit as a gastroenterologists in this type of setting, you focus more on the upper GI polyps and Emre more on the lower ones. So walk me through a little bit about how you two came together with this idea of this endoluminal surgery center to join forces, and what prompted you to see the need for this and how to work together to build the center?
Emre Gorgun: Yeah, this is very exciting actually. Amit and I'm looking forward to work together and we have been working for a while now. It is actually unique in its sense that this is a collaboration that I don't think exists in many other centers and this is going to help to streamline our patients, their needs. What I mean by that is that our center is very patient focused. That's going to help streamline any patients that will need advanced endoscopy procedures. As you mentioned, there is extremely high need in the United States nationwide, more than 30,000 colectomies colon resections removal of a 10, 12 inch of colon is performed for a benign polyp. You can imagine how drastic that is. And same thing applies even with higher morbidities or complications potentially to remove a colon. And so our goal is help patients in need, having this type of lesions, benign or precancerous lesions, whether it's an upper GI or in the lower GI area.
Amit Bhatt: I'm very excited to work with Emre Gorgun. We share the same passion of delivering mentally invasive care to patients with pre-cancers and early cancers lesions of the GI track. In parallel, both of sort of started our independent program. Emre focused on the lower end of colon polyps and early colon cancer, while my interests of being an early esophageal gastric cancer and polyposis of the upper tract.
Both of us at the infancy of these techniques went to Japan over seven years ago to learn where these techniques were developed, being endoscopic submucosal dissection and endoscopic mucosal resection, and bringing those techniques back to the clinic so we can help our patients here.
We've been doing this for the last six years with phenomenal outcomes and our programs have really grown over time. And our collaboration is about sharing ideas, resources, and putting our minds together in an area that we're passionate about so we can deliver the best care to patients and most efficiently.
And as Emre said, the awareness of these techniques is limited and the majority of patients are still undergoing traditional invasive surgery to get these lesions removed that could benefit from endoscopic surgery.
Emre Gorgun: Let's build upon that last point. So if I'm a patient out there listening, I say, "Wait a minute. So you're telling me that we have all of these particular tools that are available, but my surgeon or my gastroenterologist said I got to have a resection for that? Is that wrong?"
Amit Bhatt: No, that's not wrong. The majority of cancers or tumors do require surgical resection. But there are a subset of patients with the early type of cancer that have a low risk of it spreading outside of the GI tract to the lymph nodes that can benefit and have cured a resection from endoscopic standpoint with the same oncologic outcomes of surgery. But these patients maintain their quality of life, their GI track, and up to two weeks after an endoscopic resection go back to the same type of lifestyle that they had before.
Though, differentiating these two types of patients is very important. And that's why when a patient comes to the clinic for let's say early esophageal or early gastric cancer, they would undergo a multidisciplinary assessment. We would complete their staging with CAT scans, a PET scan and endoscopic ultrasound, and then they would see a surgeon, an oncologist, and a gastroenterologist, or a colorectal surgeon, and then we would decide in a multidisciplinary tumor board what is the best treatment for that patient. That ends up being endoluminal surgery or ESD, then we would go ahead with that.
Scott Steele: So Emre, walk me through, I'm a patient out here and I was told by my referring physician or my primary care provider that, "Hey, listen, I want you to go up to the clinic and I want you to see Dr. Gorgun in the endoluminal surgery center." What can that patient expect when they come to see you in clinic? Walk me through that journey that they're about to have.
Emre Gorgun: Sure. I think you bring up a very good point, is it wrong or not? I think I can start from there. If patient is diagnosed with a large lesion in the colon and referred to a surgeon to have their colon removed, I think that's where it starts. This is important for patients to understand that if they don't have a cancer diagnosis, maybe there is another option for them. Maybe there is a possibility that without remove getting their colon removed, a large intestine taken out, there's a possibility that we can help these patients. And this is a very common scenario that a lot of our patients search and then they come and find us and I think what we are going to help these patients is even farther in the future with with our center and helping right now, is that we can to make this more easy for them.
So all they need to do is come in, call us, get an appointment and we will meet with them, look at their findings and studies. It's very important for us to see their previous colonoscopy images or upper GI endoscopy images, and we prefer to have them definitely in in colored pictures and definitely investigate into them. Some of them are biopsied before so we get their pathologies also reviewed here at our center to make sure that what they have been diagnosed with is really accurate and what they were recommended in terms of treatment plan is really what they need. So we want to make the best decision, best treatment option for them that is out there.
Scott Steele: I'm going to backtrack to you. You mentioned a lot of different things that can happen, and granted there's differences between the upper GI track and the esophagus or the stomach and the lower GI tract with the colon and the rectum. You talked about a PET scan and an ultrasound that can happen in this multidisciplinary evaluation. So in clinic, what can they see? Do they get a scope in clinic? Do they get other tests that are set up? What are these different tests that you're talking about based on where the lesion is?
Amit Bhatt: This is if a patient came with an early cancer, this would be the setup that we want to do. And in the treatment of cancer it is important to properly stage cancer accurately. That allows us to decide what is the best treatment for a patient. Endoscopic resection is not always the best option if the tumor is more aggressive.
So we first like to start off before patients even see us in clinic is to complete that staging workup. The first part is to do a CAT scan and PET scan together, and this allows us to make sure that the tumor hasn't left its GI track to another organ within the body.
Next is an endoscopic ultrasound, which is a very simple procedure, very similar to an upper endoscopy or colonoscopy. An anesthesiologist gives them some medication to make him sleepy and comfortable. We pass a thin scope through their mouth, down their esophagus, into their stomach. And there an ultrasound probe, in the same way, an ultrasound can see a baby in a woman's belly, when we put an ultrasound in the stomach or esophagus, it allows us to see beneath the surface and allows us to see how much of the soft geo wall is involved by the tumor. This gives us an idea if this is involved, just the superficial layers or the deeper layers.
Once this information is derived, then the patient would see an endoscopist in clinic, a surgeon, so if it's an esophageal cancer, a cardiothoracic surgeon and oncologist. We will review the data, the health of the patient, go over the details and talk about this patient in a tumor board, and within a short timeframe of about a week we'll make a decision on what we think is the most optimal treatment for that patient and then schedule the next test.
Scott Steele: Emre obviously the lower GI track's sometimes a little bit different. So what type of tests, if any at all could they expect to receive based on this? Either at their local institution when some of these things come up or here when they come and see us at the clinic?
Emre Gorgun: Yes, it's a very different aspect between upper GI and lower GI. From what Dr. Bhatt explained, we do not routinely use ultrasound in the lower GI tract, but we do use a lot of diagnostic tests in terms of visualization of a lesion and these surface anatomy features, which means looking at the polyp itself with high definition scopes, whether it is also chroma endoscopy, confocal laser, there are a lot of technologies out there that we are happily utilizing here to understand the nature of the polyps, the nature of the lesions.
If the lesion is really highly suspicious for cancer, probably advanced endoscopic techniques for most cases are not, not the best approach. However, if there's no need or no risk involved with high risk features for cancer, then these are good cases for advanced endoscopic removal.
Scott Steele: Amit, do they go to sleep for this... Walk me through the actual procedure itself. Now that it's go time, they said, "You are the candidate to have this advanced endoluminal surgery." What can they expect on game day and what can they expect during the procedure?
Amit Bhatt: So this is an endoscopic procedure that requires anesthesia to do deep sedation. So what's involved is the patient would have nothing to eat or drink after midnight, stop any blood thinners about five days before the procedure. They would show up for the procedure, we would take them back. An anesthesiology would put them to sleep and we temporarily put a breathing tube in. And this is partly to just to protect the airway and stop any blood or fluid from going into the lungs.
The endoscopic resection, or ESD procedure, can take anywhere between one hour to two hours to perform, and we do this by exploiting the fact that the GI track wall is made out of five layers. The middle layer, the submucosal layer is a potential space, so when we inject fluid into this potential space, it increases the size of the layer. It allows us to enter the endoscope into the wall of the GI track, dissect underneath the tumor, removing the tumor in one complete piece while leaving the integrity of the GI track in place. The scope is removed and the patient is then woken up and taken to recovery.
The vast majority of patients go home after their procedure. 90% plus. Our recommendations are clear liquid diet for three days, three days of soft food, and then they go slowly transitioning back onto their regular diet. The majority patients are back to their normal pre resection self within a week or two after the procedure.
Scott Steele: Emre, I got to ask you the downside of this. Not everything can go smooth as silk. So what are some of the potential complications that patients should be aware of that can occur with any one of these particular procedures?
Emre Gorgun: ESD, or advanced endoscopic procedures, obviously are very interventional methods and they are higher risk than regular colonoscopy or your routine diagnostic tests. Why? Because we do more intervention. Like Amit mentioned, there's injection, there's cutting, so that's why we prefer to refer this as endoluminal surgery. So we're starting to do more and more interventions, procedures, cutting, traction interluminally, the inside of the bowel, so this is more advanced leap forward approach. Of course, that can lead to higher rates of what we call perforations or rupturing the colon.
However, these risks are very, very small and that's also the beauty of our center, collaborating between surgeons and gastroenterologists. We can immediately take care of these by putting a laparoscope in, putting a scope, like a gallbladder surgery type of approach with the camera, and instruments puncture holes into the abdomen and close these defects. Or even if needed, immediate real time a bowel resection, let's say if the tumor looks really suspicious when we're doing this procedure, or the hole is large enough that cannot be closed with endoscopy or laparoscopic techniques.
Scott Steele: I've heard you both say before that this is not a one and done shop. This is something that you're going to follow patients ahead. So what can patients expect after the procedure? Do you guys see them again? How often do you see them again? Do you refer them back? Obviously if they come from a ways away, that may not be the case, but what is the general expectation about how you follow some of these more advanced non-cancerous or early cancerous lesions?
Amit Bhatt: I think one of the most important parts of the endoscopic treatment of cancer is actually the follow-up. One of the downsides of endoscopic resection of cancer is while we allow the patient to keep their native organ, while that allows them to keep their quality of life, it's also the same organ that developed the cancer in the first case. And these patients are at risk of developing an additional cancer later on their life.
So the best thing that we can do to keep their quality of life going long term is to make sure that we do a good surveillance program. So if any tumor does occur, we can catch it early. For a patient that's would like to come to the Cleveland Clinic and it is practical for them to come, we would love to take care of them. We want to become their medical home, a place that they can come to get their surveillance tests done and other checkups.
For instance, for an esophageal tumor, we would recommend an upper endoscopy and CAT scans every six months for the first two years, then yearly afterwards. For those patients who come from out of states, and it's really not practical to come here to the Cleveland Clinic, we're happy to work with the referring doctor to make sure those surveillance has get done.
Scott Steele: So as we wind down here, I will ask the both of you, Emre, I'll start with you. What's on the horizon as far as you can see in terms of research and endoluminal surgery and making sure that we achieve the best patient outcomes?
Emre Gorgun: Yes. Research is very important and it's a crucial aspect of our center as well. We have multiple projects together moving forward, so one of them check the recurrence rates and of course you look at our experiences here and outcomes. Additional benefits of this procedure is also, of course, the minimal burden on the health care in terms of the cost, so we are also checking our experiences from this perspective. Also, creating possibly CPT codes and how we can document and code these in our healthcare system.
Additionally, the other aspect of your question is what are the next advancement in the horizon? We are very excited also to be deleting center in terms of bringing the endoluminal surgery to the next level. How can we do that? There is a lot of technologies and ideas that also we have to increase our abilities interfluminally, inside of the intestine to bring more instruments, maybe in the sense of different platforms or even endo robotics, and be able to do more complex procedures and endoluminal. This can even lead us to the next level, even going to the bowel and possibly, or potentially, doing procedures intra abdominally using these natural orifices.
Scott Steele: Amit?
Amit Bhatt: Absolutely. This is actually one of the exciting parts of our collaboration, is that both me and Emre on the forefront of helping develop new technologies in our animal labs, working together to make these procedures easier and safer to perform. Some of these devices we've actually developed ourselves within the Cleveland Clinic and are helping with the commercialization. We're looking for them to become public next year.
Scott Steele: Well gentlemen, that's very exciting stuff and as all the listeners know, we'd like to end up with each of our guests on a couple of quick hitters. So to the both of you, what's your favorite sport?
Amit Bhatt: My favorite sport is soccer.
Scott Steele: Em?
Emre Gorgun: Sailing.
Scott Steele: Favorite food?
Amit Bhatt: Ramen noodles.
Emre Gorgun: Sushi.
Scott Steele: Last nonmedical book that you've read?
Amit Bhatt: Bad Blood.
Emre Gorgun: I read the same one, Bad Blood.
Amit Bhatt: It's a great book.
Scott Steele: Something that you enjoy about Cleveland.
Amit Bhatt: I love Cleveland. I have two small boys and Cleveland is a beautiful city with great orchestra, museums and a great place to raise a family.
Emre Gorgun: Diversity and the lake.
Scott Steele: Well, that's fantastic stuff, and we're very, very excited that this collaboration has started and look forward to future increased benefits for all of our patients.
So for more information on Cleveland Clinics and endoluminal surgery center, please visit clevelandclinic.org/digestive. That's clevelandclinic.org/digestive. D-I-G-E-S-T-I-V-E. And to speak with a specialist at the endoluminal surgery center, please call (216) 444-1244. That's (216) 444-1244.
Gentlemen, thanks for joining us on Butts & Guts.
Amit Bhatt: Thank you so much.
Emre Gorgun: Thank you for having us.
Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.