Cleveland Clinic's Endoluminal Surgery Center and Lesions in the Upper Tract

Podcast Transcript

Dale Shepard, MD, PhD: Cancer Advances, a Cleveland Clinic podcast for medical professionals, exploring the latest, innovative research and clinical advances in the field of oncology. Thank you for joining us for another episode of Cancer Advances. I'm your host, Dr. Dale Shepard, a medical oncologist here at Cleveland Clinic overseeing our Taussig Phase I and Sarcoma Programs. Today, I'm happy to be joined by Dr. Amit Bhatt, an advanced endoscopist and co-director of the Endoluminal Surgery Center at Cleveland Clinic. In another episode of this podcast, I talked to Dr. Gorgan about management of lesions in the lower GI tract. Dr. Bhatt is here today to discuss management of lesions in the upper GI tract. So, welcome.

Amit Bhatt, MD: Hey, good morning, and thank you so much for having us, Dale.

Dale Shepard, MD, PhD: Absolutely. So, maybe to start, just tell us a little bit about your role at Cleveland Clinic. What do you do here, and we'll talk specifically about the Endoluminal Center, but what do you do here?

Amit Bhatt, MD: So, I am one of the advanced endoscopists. So, we go through our gastroenterology fellowship training, and then a year of advanced endoscopy, where we learn to perform what are called advanced endoscopy procedures, like endoscopic ultrasound, ERCP, and endoscopic resection procedures. Most of my time is spent performing those procedures and helping our patients here at the Cleveland Clinic.

Dale Shepard, MD, PhD: So, endoluminal surgery is not very common. Tell us a little bit about how you got involved with endoluminal surgery.

Amit Bhatt, MD: I think, both, me and Emery, independently, had got interested in these techniques. This, for me, happened organically very early in my career. When I was a fellow here at the Cleveland Clinic, we would see these rare videos coming out from Japan of an intricate procedure they were using to treat early esophageal and gastric cancer. The technique was called endoscopic submucosal dissection, or ESD for short, and the procedure was rarely performed in the West and little was known about it.

So, it was not possible to learn the techniques here, so I was fortunate to be awarded grants from our GI societies and spent four months of my fellowship in Japan at the National Cancer Center Hospital in Tokyo, Japan, to learn ESD from the hospital that it was invented at.

The cancer makeup in Japan is very different than the West. Gastric cancer was actually their number one cancer for a large part of the last decade, and they spent significant effort to develop techniques to detect and treat gastric cancer at an early stage. The technique, itself, is intricate, beautiful, but very technically-challenging to perform.

But when I was there, what amazed me the most wasn't the technique, but the benefit it gave to patients. I saw many patients there undergo endoscopic resection, who would require major surgery here, allowing them to keep their original organs and their quality of life. So, I was sold.

I dedicated quite a lot of my time to learn these techniques and to perform them well. In 2016, when I was hired at Advanced Endoscopy Center here at the Cleveland Clinic, we started our program, performing the first endoscopic resections of early gastric and esophageal cancer.

So, that started me on this journey towards this idea of, what we call, operating in the GI tract, going in with an endoscope, taking tools, knives, and being able to, very precisely, dissect tumors out completely and in one piece, but leaving the patient's organ in place, and this allows patients to basically have the same quality of life that they did prior to the endoscopic resection.

Dale Shepard, MD, PhD: That's probably exceedingly important in the upper GI tract, where people, if they lose part of their stomach, they have significant problems with eating, for instance?

Amit Bhatt, MD: Absolutely right. I think surgery for the upper GI tract is much larger undertaking than surgery for the colon. This is, especially, in particular important for esophageal cancer, that tends to happen in more elderly patients with comorbidities, that may not be good candidates for an esophagectomy. As you know, even performing esophagectomy, itself, carries its own risks of mortality, and not everybody gets off the table.

Dale Shepard, MD, PhD: So, what drove you and Dr. Gorgan to set up a center? Tell us a little bit about that.

Amit Bhatt, MD: I think, as with most things, the original growth of our programs was very organic. It was different physicians or patients telling each other about this, and then sooner or later, Dr. Gorgan and me realized that we had the same passion for doing these techniques and helping our patients. So, it was natural and organic for us to team up to form the Endoluminal Surgery Center, a center that's focused on delivering the highest level of complete care to patients with early gastrointestinal neoplasia.

That includes pre-cancerous and early cancerous lesions of the esophagus, stomach, small bowel, and colon. It's great to work together with Emery. It's something that we both have passion for. He's focused on the lower tract with colon polyps, while I focus mostly on esophageal gastric cancer and DWAMA polyps, and together, we can combine our resources or knowledge to help basically develop the finest program for our patients.

Dale Shepard, MD, PhD: How do patients, with an upper GI lesion, how do they typically get to you? Is this something where they may have a local GI doc that goes in and sees something, and refers them, or are these primarily people who you're making an initial diagnosis? What's the typical patient that you see?

Amit Bhatt, MD: For the most part, most of our patients are referred to us. We're not making that initial diagnosis. It's either by the referring doctor suspecting this might be an earlier cancer and sending it towards us, or sometimes we have patients actually look up on the internet, and they're looking for the best care for their tumor and they find us, themselves.

Dale Shepard, MD, PhD: Is there an ideal scenario, an ideal patient, that you think would be suited to be referred to you? Is there a particular size or complexity of a tumor, a location, something that's best-suited to come see you?

Amit Bhatt, MD: I think for the most part, we are happy to evaluate all patients that somebody might suspect early cancer. That way, we have the ability to be able to determine if that's really the case or not. We're happy to see patients we're not actually going to do therapy on, just to make sure that they get on the right path.

I think the things that are most important to us, things that referring physicians can do to help us out, is the minute one of these tumors get scarred, it becomes much more difficult for us to do our job. I think if you identify a tumor that you might think is on the earlier side, minimize interventions.

Sometimes, we have lesions that somebody partially resects, or puts clips on, or injects tattoo underneath. Those things are actually not helpful for us and actually make our job much harder. So, if you see something that may be an early cancer, take one single biopsy off it, and then send it to us, and we'll be happy to take care of the rest.

Dale Shepard, MD, PhD: Tell me a little bit about the multidisciplinary nature of the center. Who is all involved with that?

Amit Bhatt, MD: Yeah. I think that's one very important point to our program, is this is not sort of one individual making all the decisions, but in early cancer, it's very important to have multidisciplinary evaluation and treatment. We work very closely with our cardiothoracic surgeons, our general surgeons, and oncologists to deliver the best level of care.

For instance, I'll give an example of somebody with a suspected early esophageal cancer, and what is their pathway? Let's say a patient is referred to us for suspected early esophageal cancer. They would first come in and complete their staging tests, which would include an endoscopic ultrasound, a PET and CT scan. Then they would see us, our thoracic surgeons at our oncologists in clinic. We would discuss that case at a multidisciplinary tumor board, and a collaborative decision is made on the patient's best treatment.

It's important to know that many, I would say probably 3 out of 10 patients who have suspected early esophageal cancer probably have a more advanced tumor, and that framework of a multidisciplinary approach lets us make sure that those patients go on to treatments that are more specific to their advanced cancer. If a decision is made that they go under endoscopic submucosal dissection, we would then proceed with the procedure, and the patient would follow up in our clinics in two to three weeks after resection to discuss the pathology and next steps.

Dale Shepard, MD, PhD: So when we think about tumors that are maybe more or less likely to be successfully treated, does that exist? Is an adenocarcinoma different than a gist, for instance?

Amit Bhatt, MD: Yeah. I think all tumors have their unique biology and risks. The main difference between the endoscopic resection of the cancer and surgical resection of the cancer is, there's absence of lymph node dissection with endoscopic techniques. So basically, endoscopic technique should only be used on tumors that have a very low or negligible risk of spreading to lymph nodes.

Part of the art of deciding which patient is amenable to endoscopic resection is understanding, what is the lymph node risk for that tumor, and individualizing it to see which patient should go to surgery or not. For instance, if we look at the esophagus, it's mostly depth of invasion that defines the risk of invasion. Squamous cell cancer tends to invade at a much lower depth than adenocarcinoma. So, we have a little more leeway to do early T1B or tumors that involve the submucosa than patients who have an adenocarcinoma, but for squamous cell cancer, the risk of leptospirosis metastases goes up too high, and it invades into the submucosa. So, those are not amenable to curative endoscopic resection.

Dale Shepard, MD, PhD: What are the biggest limitations currently?

Amit Bhatt, MD: I think over the last five years, these have gone from extremely technically-challenging procedures to making them much easier to perform. Part of the limitation of endoscopic surgery is, it's done through one flexible endoscope. There's lack of stability, and there's also lack of triangulation, which means there's not a surgeon second hand, for instance, lifting the lesion up so you can dissect it.

Recently, and we're happy to be part of this, we've actually developed that surgeon second hand here at the Cleveland Clinic. It's a retraction device that we put on the back of the tumor that helps lift it up and dissect underneath the plague. That device has been licensed to Medtronics and has come out commercially in the last few months. That has really us be able to perform these procedures much better.

Dale Shepard, MD, PhD: How common are these procedures? We are certainly doing them here, at the Cleveland Clinic. Is this mostly confined to large academic centers, a very few number of centers? How widespread is the use of this here, in the United States, now?

Amit Bhatt, MD: I think there are many patients who can benefit from endoscopic resection, or ESC resection of their tumor, but most of these patients in the US are undergoing surgical resection. I think one part is, we really need to spread the knowledge that these procedures exist and that patients can benefit from it. I think from their overall quality of life and outcomes, moving forward, oncologically, we can deliver the same oncologic outcomes with surgery that allow them to keep their quality of life. So, one is getting those appropriate patients in to get the procedure.

Dale Shepard, MD, PhD: Are oncologic outcomes similar for all areas in the upper GI tract for the esophagus, the stomach, the small bowel? Is that pretty consistent throughout?

Amit Bhatt, MD: I think there's some variation, for sure, and part of it is the technique was developed for gastric cancer. So, the large majority of data has come out, regarding the outcomes of gastric adenocarcinoma. There is good outcome data for squamous cell cancer of the esophagus, as well, which is the main type of esophageal cancer in Asia, where the majority procedure perform.

Adenocarcinoma of the esophagus is extremely rare, actually, in Asia and Japan, and that thought that's the most common form of cancer that we have here in the West. So now, we're seeing, in the last few years, a number of data coming out of the outcomes of esophageal adenocarcinoma. We just published a recent multi-center study that shows that 90%, plus, curative resection rates for these techniques for esophageal adenocarcinoma.

Dale Shepard, MD, PhD: That's great. Since surgery has been the mainstay of this, then, of course, habit drives lots of decisions by patients and physicians, have you noticed that there's a reluctance by either referring physicians or by patients to take on what's still a relatively new procedure?

Amit Bhatt, MD: I think to begin with, it's not, actually. There is this perception, it's a relatively new procedure. It actually isn't. It was developed over 20 years ago and has become the mainstay of treatment now in Asia and has entered our guidelines in the West as sort of standard of care for these early cancers. I think this notion that this is a novel, new and proven treatment isn't true, but that perception is out there.

First, I want to debunk that. Two, I think patients are, actually, they seek us out. From the patient standpoint, they're very eager to go under these procedures, because they can see the benefits to them at the end of the day. We have patients with advanced tumors coming for ESC, and we have to tell them they may not be candidates.

I think one of the biggest barriers is sort of just referral patterns over time, traditionally, a gastroenterologist or endosepsis, were sending these to their surgeons, and that's the paradigm that we have to shift there. So, I would say that's the biggest barrier.

Dale Shepard, MD, PhD: What about insurance? These are in the guidelines. These are standard procedures. Are there any insurance barriers?

Amit Bhatt, MD: I think more so for reimbursement. The barriers for us is, endoscopic technique is advancing so quickly, we don't have the billing codes to be able to support many of these techniques. There's a lot of work at the society levels to do that. Here at the clinic, write a letter to our insurance companies, and we haven't had much resistance to them, except for these techniques. Compared to the counterpart of surgery, they're far cheaper than a patient undergoing surgical resection.

Dale Shepard, MD, PhD: I mean, I guess just from an understanding from physicians that may be thinking about sending a patient, what does it look like for the patient? What would their treatment look like? How long would that take? What's their recovery look like? Would they be here for a prolonged period of time for that recovery, or would they be home quickly?

Amit Bhatt, MD: I can certainly walk you through the entire process of a patient. We've put a lot of efforts into that experience. If a physician refers a patient, any with early suspected cancer, we try to complete the entire valuation to treatment within 30 days. We bring them in and try to get their staging tests done as quick as possible. We schedule their clinic visits mostly in one day with our surgeons, with me and with oncology, if necessary.

That next week, we will discuss them at tumor board and make a decision moving forward. During that time, we've already reserved a spot for their ESC procedure, if that's what goes through, and then the patient would come in, have nothing to eat or drink after midnight. An anesthesiologist would do general anesthesia, put them to sleep, and the procedure can take anywhere between 45 minutes to two hours. It's a microdissection and a very intricate procedure. They would, then afterwards, go into recovery.

Before, at the beginning, we were hospitalizing patients afterwards, but I would say the vast majority, 90, plus, go home right after the procedure. We brought that area to give them some time to heal and not be irritated. They have three days of liquid diet, three days of soft diet, and then they resume a normal diet.

We have a clinic visit in two to three weeks to discuss the pathology, how they're doing, and next steps. That visit is very important because I sort of told you about the risk of lymph node metastases, and that's based on the depth of invasion, the presence of lymphovascular invasion [inaudible 00:18:07]. A lot of those features aren't actually known before we resect a tumor. We might guesstimate or estimate them, but once we take an entire tumor, give it to a pathologist, they can tell us how many high-risk features there are.

At that point, we make a decision. If it's a low-risk tumor, the patients can go on to have endoscopic surveillance, but if it's a high-risk tumor, they might have to go under additional therapy. For instance, like radiation or sometimes surgery if they're a fit candidate.

Now, one of the limitations of the endoscopic resection of cancer is, we leave the at-risk organ in place. So, that's the benefit. You get to keep your organ and avoid the changes in lifestyle or morbidity associated with losing your organ, but that organ is still at risk of developing further cancer.

One important point is, after they're done with their procedure, they have to have surveillance moving forward. Now, up to where the patient comes from, that can either be done locally by their physician, or if that's not available, we are more than happy to take on that role of doing their surveillance and making sure they're clean, and if something was to develop, that we catch it an early stage, that is easily treatable.

Dale Shepard, MD, PhD: Very good. Where do you see the Endoluminal Surgery Center going in the next couple or three years?

Amit Bhatt, MD: We really want to expand. I think we've really... This has been kind of a grassroot movement of treating these patients, and we've been fortunate to have exceptional outcomes over the last seven years, and now we really want to make sure that more patients, regionally, here in Ohio, and elsewhere, are able to get that same level of care, and really be able to expand our presence, and allowing patients come in.

Our focus is not on one particular technique, itself. It is to deliver the best patient care that we can. So, we're not focused on just ESD, but also embracing the next generation of technology that's coming out to help these patients, and then third is quality. Right? I think what is really important to us is delivering high-quality of care to our patients. We like to track that. We are developing a dashboard that allows us to know what the outcomes of our patients are, how many got curative resection, how many had maybe adverse events, like bleeding, and it also allows us to track them to make sure that they're getting their surveillance, moving forward.

Dale Shepard, MD, PhD: Very good. Well, you've provided some great insight today. To learn more about Cleveland Clinic's Endoluminal Surgery Center, or to refer a patient, please call (216) 444-9246. That's (216) 444-9246. You can also visit the website at clevelandclinic.org/ELS. That's clevelandclinic.org/ELS.

Thank you very much for being with us today.

Amit Bhatt, MD: Thank you very much, Dale.

Dale Shepard, MD, PhD: This concludes this episode of Cancer Advances. You will find additional podcast episodes on our website, clevelandclinic.org/canceradvancespodcast. Subscribe to the podcast on iTunes, Google play, Spotify, SoundCloud, or wherever you listen to podcasts, and don't forget, you can access real-time updates from Cleveland Clinic's Cancer Center experts on our Consult QD website, at consultqd.clevelandclinic.org/cancer.Thank you for listening. Please join us again soon.