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The implementation of the newest methods of endoscopic diagnosis and surgery in Armenia. Master Class in Nairi Medical Centre

The implementation of the newest methods of endoscopic diagnosis and surgery in Armenia. Master Class in Nairi Medical Centre

Endoscopy is the method of examination of internal organs with the help of a special instrument (endoscope).  Gastrointestinal endoscopy is one of the best methods of diagnosis without surgical intervention, and the most often method of instrumental examination of the patients. The examination is performed by an endoscope with an eyepiece at one end, that allows to visualize an image of the examined organ, and the camera at other end transmitting an image from different gastrointestinal areas. Experienced specialists can detect the problem at an early stage of development and timely prescribe a necessary treatment.

Who needs an endoscopic examination?

Patient can undergo endoscopic examination, based on an own complaints or for preventive purposes. By modern standards the examination of the upper GI tract (EGD) is recommended to perform at least once a year, colonoscopy – once every three years. If the patient is over the age of 40, the endoscopic diagnosis should be performed as an element of clinical examination. Due to such regular examinations it is able to identify tumors and malformations of GI at an early stage, when it is possible not only surgical, but also endoscopic removal of the most tumors with preservation of organs; while the percentage of recovery is, of course, significantly higher, than in the treatment of neglected forms.

At present there are no contraindications for endoscopy implementation. Modern technologies allow to perform stomach endoscopy under general anesthesia. Such procedure is carried out under control of anesthesiologist. During and after the procedure the patient doesn`t feel discomfort or any unpleasant feelings. The examinations are short, however, it should be taken into consideration that the duration of each procedure is individual and depends on a number of factors.

New methods in endoscopy

 POEM.

The advantages of new method of peroral endoscopic myotomy (POEM) is that it carried out without any incision on the abdomen and there is no risk of uncontrolled perforation of an esophagus that may occur during a balloon dilatation. Besides, such type of myotomy (dissection of muscles) can be implemented in more extent of the esophagus. POEM has demonstrative its relative security not only in the terms of risk of infection, but also in question of hemodynamic, respiratory and metabolic disorders.  No one of the surgeries was complicated by the development of such serious complications as mediastinitis or peritonitis.

EUS.

Today the doctors have a unique method of performing   ultrasound examination from the close to the examining organ distance. This method is called endoscopic ultrasound examination (EUS). It allows to examine internal organs from the inside in details, seeing changes that are inaccessible in standard ultrasound examination. Examinations are implemented with the help of a special endoscope, at the end of which is not only an optic instrument, but also a tiny ultrasound probe. Usual ultrasound examination is carried out through the skin. Ultrasound, reflecting from the internal organs, comes back to ultrasound probe and makes it possible to receive the image on a computer screen. However, the power of ultrasound waves goes out in the depth of the tissues, and many organs cannot be examined in details.  EUS allows to perform ultrasound examination of hollow organs of GI tract, in which echoendoscope is inserted (walls of esophagus, stomach, colon and rectum), as well as to abdominal organs, which are located nearby to stomach or intestine.   These are pancreas, bile ducts, gallbladder and liver. Ultrasound scan through esophagus makes possible to create an image of mediastinal organs. In addition to internal organs, can be identified the condition of lymph nodes, located in the abdominal cavity or chest cavity.

Endoscopic ultrasound elastography

Sonoelastography during EUS allows to characterize and differentiate benign   and malignant changes of lymph nodes with a high sensitivity, specificity and accuracy. Sonoelastography image complement other modes of scanning in EUS and allow more precisely to carry out fine-needle aspiration biopsy in the case of multiple lymph nodes.

 The primary indications to EUS are diagnosis of formations in esophageal walls, stomach, duodenum of both benign (polyps, submucosal formations, extra-organ compression, cysts), and malignant lesions. It is important to diagnose not only the formation, but also to determine, from which layers it emanates, to what level it grows, whether the regional lymph nodes are involved. To all these questions can answer only EUS.

  • Diagnosis of diseases of the pancreas (acute and chronic  pancreatitis,cysts, tumors,stones).
  • Diagnosis of diseases of gallbladder and biliary tract. Especially lesions of exit areas of bile and pancreatic ducts  and papilla of Vater. These areas are less accessible to other diagnostic methods.
  • Diagnosis of mediastinal formations.
  • Clarification of the degree of development of varicose veins in the esophagus and stomach with  liver diseases for a choice of tacticts of treatment and prophylaxis of variceal bleeding.
  • Search of anastomoses with the deep veins

Diseases, for diagnosis of which is used endoscopic ultrasound

An unquestionable merits of endoscopic ultrasound make this method indispensible for the early detection of the following diseases:

  • Submucosal tumors of esophagus, stomach, duodenum and colon (fibroma, lipoma, leiomyoma)
  • Stomach, esophagus, duodenum and colon cancer
  • Esophageal varices
  • Esophageal, gastric, duodenal and colon deformation
  • Gastric, esophageal, duodenal ulcerative diseases
  • Diseases of the biliary tract, including the formation of stones in the biliary tract (choledocholithiasis)
  • Diseases of the pancreatic  duct, including cyst of pancreas

Endoscopic examinations are carried out with the help of digital video-endoscopic system of the last generation- PENTAX Hi-LineHD+ (Japan)

 The unique HD+ resolution, 1.5 times exceeding in the clarity all well known analogues of endoscopic system, innovational technology of improvement of the image allows to study mucous membrane of gastrointestinal tract and detect minimal pathologic changes, including precancerous diseases and the early stages of malignant tumors. The rate of detection of adenoma with the use of the system  PENTAX Hi_Line HD+  significantly exceeds the standard endoscopy. The i-scan function allows to improve the quality of image of mucous structure  for the rapid detection of the lesion, virtual chromoendoscopy helps for  the proper diagnosing  without using vital dyes, which reduces the time of examination.

 In 2016 September 10th from the early morning till night, for the first time in Armenia in Nairi MC were carried out the rarest surgical intervention cases of 8 patients with various pathologies of gastrointestinal tract. The last generation endoscope of expert class and EUS that was brought and presented by Russian branch of  PENTAX was used in these cases.  Arrived from St. Petersburg (Russia) the head of endoscopy department of the Institute of Surgery and Emergency Medicine of Medical University after Pavlov, Dr Smirnov A.A. (Ph.D.) conducted master class with demonstration of diagnostic, surgical and endoscopic methods. In Russia such kind of surgeries are carry out only by two specialists, one of them is Smirnov A.A.

Many professionals in the field of endoscopy were invited. Cameras mounted in a conference hall and operating room allowed to monitor the operation online, and were highlighted both by Dr Smirnov A.A. and doctors of Nairi and Erebouni MC. Consultations and observations were conducted by resuscitators (intensivists), thoracic surgeons and general surgeons.

The first patient S.A. has admitted to Nairi MC with the diagnosis: esophageal achalasia, esophageal spasm.

Achalasia of cardiae is the disease, characterized by gradual development of esophageal impassability on the level of esophageal-gastric junction, caused by impaired relaxation of the lower esophageal sphincter and lose of normal contractility of esophageal muscles.

Clinically achalasia cardiae is manifested in the progressive impairment  of  the swallowing function, leaking the content of esophagus into respiratory tract, loss of weight, that significantly decreases the quality of life of the patients. In case of development of persistent narrowing of the esophagus the necessity of surgical interventions may occur.

During surgery in esophageal achalasia the endoscope is introduced through the patient`s mouth and reaches the esophageal muscles. This allows to make the incision directly into the ring muscle, that eliminates the pressure on the esophagus and allows food to pass down smoothly. 

The peroral endoscopic myotomy (POEM) procedure was performed under the general anesthesia. The procedure lasted approximately 2 hours and 40 min. Myotomy was carried on 25 cm of esophageal length, which itself is unique, since in such kind of surgeries (even open) the length isn`t more than 10 cm. The operation was successful, post-operative period was uneventful. The patient was discharged on the 4th day.

It is necessary to note that the presence of multidisciplinary surgical team was needed, because there was a risk of esophageal perforation, which is inherent in such kind of surgeries.

Two patients have been admitted to Nairi MC with the diagnosis: Tumor of the head of the pancreas. EUS alongside with biopsy was performed.

Two more patients have admitted to Nairi MC with diagnosis: Barett`s esophagus. EUS alongside with biopsy was performed.

Two another patient has admitted to Nairi MC with diagnosis: Tumor of the colon.

 Removal of tumor was carried out by dissection. (Effective, but technical very complexed method of removal of esophageal and gastric epithelial tumors)

And one patient has admitted to Nairi MC with diagnosis: Gastric  tumor EUS  diagnostic examination was performed.

It is important to highlight, that such kind of surgery was performed in Armenia, in Nairi MC for the first time! 

It is essential to note, that all patients, to whom have been performed diagnostic or surgical endoscopy were discharged the same day, some of them – the next day after procedure.

Certainly, such kind of interventions should be performed using modern technical equipment, with a high professional Anesthesiology Service and carefully post-operational monitoring of the patients. It is extremely important to note the fact, that such kind of surgeries have higher percentage of rehabilitation and early return to a usual lifestyle, without affecting on the quality of life.

Advantages of endoscopic ultrasound to other methods of examination

 Ultrasound examination makes possible to identify abnormalities of internal organs, but only at a certain distance, beyond which neoplasms remain hidden for the doctors. Thus, there is a definite area, where neoplasms can`t be detected neither with endoscope nor by a usual ultrasound. Somehow this problem is solved by CT scanning. However, endoscopic ultrasound has significant advantages compared to all other methods, that allows to detect a number of serious diseases at an early stage, and thus increase the effectiveness of the treatment. Endoscopic ultrasound instrument allows to perform ultrasound examination of internal organs, including areas, inaccessible for a usual ultrasound. Unlike the CT scan, endoscopic ultrasound allows to examine internal cavities in various planes, following to the direction of the duct. In addition, while performing endoscopic ultrasound examination, is also possible the implementing of visually controlled sighting biopsy from the certain area of tissue under the guidance of ultrasound.

All these benefits of diagnostic and surgical endoscopy over other methods raise the diagnosis and treatment of digestive system diseases to a new level.

13 September 2016