Gastrointestinal Endoscopy

The Department of Digestive Endoscopy currently has 6 full-time physicians, all of whom hold postgraduate degrees or above, with doctorate holders accounting for 33.3%. The discipline is led by Professor Gong Aixia, M.D., a master's supervisor, who currently serves as a National Committee Member of the Digestive Endoscopy Branch of the Chinese Medical Association and Vice Chairman of the Digestive Endoscopy Branch of Liaoning Province. The discipline has established 4 subspecialty directions, including the diagnosis and treatment of early gastrointestinal cancer, therapeutic ERCP, endoscopic ultrasonography, and the diagnosis and treatment of small intestinal diseases, covering essentially all of the latest developments in digestive endoscopy technology.

Apart from routine gastroscopy and colonoscopy examinations, what other minimally invasive treatments can the endoscopy room perform?

The techniques currently performed by the Department of Digestive Endoscopy include:

Endoscopic ultrasonography, endoscopic polypectomy, endoscopic submucosal dissection (ESD), placement of triple-lumen feeding tubes or intestinal obstruction catheters, gastrostomy, silver clip hemostasis, sclerotherapy or band ligation of esophageal varices, removal of foreign bodies from the esophagus or stomach, balloon dilation of esophageal strictures, esophageal stent placement, peroral endoscopic tunnel technique for achalasia (POEM), botulinum toxin injection at the cardia, and endoscopic retrograde cholangiopancreatography (ERCP), among a series of other minimally invasive treatments. Among these, ESD, POEM, and ERCP have reached an advanced domestic level.

I. Endoscopic Submucosal Dissection (ESD)

Introduction to ESD:

Gastrointestinal tumors are the most common malignant tumors and seriously affect the health of the people. Gastric cancer is currently the fourth most common malignant tumor worldwide and ranks second among tumors in terms of mortality; the incidence of gastric cancer is 14.1 per 100,000, and the mortality rate is 10.3 per 100,000. China is a country with a high incidence of gastric cancer, with new cases each year accounting for 40% of the global total. The incidence of colorectal cancer is 14.2 per 100,000; the mortality rate is 6.9 per 100,000. Early gastric cancer has a good prognosis, with a 5-year survival rate of 84%-99% after treatment.

The development of normal digestive tract mucosa through precancerous lesions into cancer is a gradual process. Therefore, early detection and early treatment of precancerous lesions and early cancer are key to improving survival rates and quality of life. Surgery was once considered the standard method for treating early gastrointestinal cancer. Although surgery can completely remove the lesion, it involves major trauma and slow recovery, with an average hospital stay of 25 days, high medical costs, a high incidence of postoperative complications, and poor postoperative quality of life. Finding a treatment for precancerous lesions and early cancer that is minimally invasive with rapid recovery is a goal physicians have long dreamed of. Endoscopic treatment is minimally invasive: it both ensures complete tumor removal and preserves normal tissue and its function to the greatest extent, with a low incidence of complications and a marked improvement in patients' postoperative quality of life. Choosing endoscopic treatment for early gastrointestinal cancer has been accepted by more and more physicians. At the end of the 1990s, endoscopic submucosal dissection (ESD) was first developed in Japan; through the endoscope, larger areas of superficial lesions can be completely removed in a single session — another milestone in the development of endoscopic technology. Only a small number of Grade III Grade A hospitals in China have carried out this technique; our hospital has performed it for 2 years and is the only hospital in Dalian to perform it independently.

ESD Cases:

Endoscopic submucosal dissection (ESD) has been performed in China for nearly 10 years. The Department of Digestive Endoscopy of the First Affiliated Hospital of Dalian Medical University, led by Director Gong Aixia, began using this technique in April 2011 and has cured more than a hundred patients in Dalian with early gastrointestinal cancer and precancerous lesions.

ESD directly uses very common medical instruments — the gastroscope and colonoscope — to remove early cancer and precancerous lesions. No open surgery is required; not even the small incision of minimally invasive surgery is needed, yet the goal of complete lesion removal can still be achieved. Patients and families who have received this treatment praise it unreservedly.

With the continuous development of digestive endoscopic diagnosis and treatment techniques, the vast majority of gastrointestinal polyps, early cancers, and precancerous lesions can now be removed endoscopically, without the need for traditional open surgery.

Under the leadership of Director Gong Aixia, the Department of Digestive Endoscopy of the First Affiliated Hospital of Dalian Medical University performs endoscopic submucosal dissection (ESD), using minimally invasive techniques to complete large-area mucosal dissection of the gastrointestinal tract, fully replacing traditional open surgery for the treatment of gastric cancer and precancerous lesions. This minimally invasive treatment not only relieves the suffering of patients being treated for gastric disease but also improves their postoperative quality of life.

It is mainly used to treat: esophageal lesions, gastric lesions, colorectal lesions, early gastrointestinal cancer, laterally spreading tumors (LST), giant polyps, carcinoid tumors, and submucosal tumors, achieving one-session complete removal of larger lesions without open surgery.

ESD provides precise diagnosis; the treatment is safe, simple, and rapid, requiring no open surgery, painless and minimally invasive; patients can be discharged in only 3-6 days, greatly reducing treatment costs and treatment-related suffering.

Advantages of endoscopic submucosal dissection (ESD) treatment:

① It can remove lesions larger than 2 cm in a single session, reducing the problem of high recurrence rates caused by multiple removals.

② ESD is the ideal treatment that enables en bloc, single-session removal of early gastrointestinal cancer without surgery, while allowing precise histopathological diagnosis.

③ Compared with gastrointestinal surgery, ESD reduces the incidence of complications and mortality, and patients' postoperative quality of life is comparable to that seen in advanced-stage cancer.

④ In recent years, instruments dedicated to ESD have been developed and improved, including the recently introduced IT2 knife, Dual knife, Flush knife, and Hybrid knife.

⑤ It is a highly suitable treatment method for patients with various benign tumors, early cancer, advanced age or frailty, surgical contraindications, or submucosal cancer with suspected lymph node metastasis who refuse surgery.

At present, only the Department of Digestive Endoscopy of the First Affiliated Hospital of Dalian Medical University in Dalian performs this technique. Although ESD has been performed in China for only 8-9 years, its superiority in treating early gastrointestinal cancer has been widely recognized. Whether a hospital can perform ESD has become a benchmark of its endoscopic capability. Domestic scholars attach great importance and interest to this new ESD technique. Led by Director Gong Aixia, the Department of Digestive Endoscopy of the First Affiliated Hospital of Dalian Medical University began gastrointestinal ESD work and has completed more than a hundred ESD treatments to date, accumulating rich experience.

The Department of Digestive Endoscopy of the First Affiliated Hospital of Dalian Medical University holds a leading position in Dalian in terms of diagnostic and treatment services and their quality; it also constantly strives for excellence in discipline building and scientific research. We need not only to refine our medical techniques, improve our services, and achieve new breakthroughs in research, but also to do things in greater detail and better, striving to contribute to the cause of endoscopy in Dalian.

II. Endoscopic Tunnel Technique (POEM)

Introduction to POEM:

Achalasia is a functional disorder caused by neuromuscular dysfunction at the esophagogastric junction. Its main clinical manifestations are dysphagia, regurgitation of food, and retrosternal pain. Epidemiological data on this disease are lacking in China; in Western countries such as Europe and the United States, its incidence is about 1 per 100,000 per year. At present, the main methods for treating achalasia at home and abroad are: 1. dilation therapy; 2. endoscopic injection of botulinum toxin type A; 3. endoscopic microwave incision and sclerosant injection therapy; 4. surgical Heller myotomy. These treatments have obvious short-term effects but poor long-term outcomes, with frequent recurrence; balloon dilation also carries risks of perforation and bleeding. Surgery was once considered the standard treatment and can be performed via the thorax or the abdomen, or with thoracoscopy or laparoscopy; the surgical trauma is large and the hospitalization long, with reflux esophagitis as the main long-term complication, hence the addition of anti-reflux surgery. With the continuous emergence of new medical technologies and equipment and the deepening of the minimally invasive concept, in 2009 peroral endoscopic myotomy (POEM) was successfully used to treat achalasia. With no skin incision, the circular muscle layer of the cardia is incised under the endoscope, restoring the physiological function of the esophagus to the greatest extent and reducing surgical complications; patients can eat in the early postoperative period; dysphagia is relieved in 95% of patients, and the incidence of reflux esophagitis is low. Because this technique completely cuts the circular sphincter at the lower end of the esophagus, symptom relief is marked and recurrence is uncommon, with good short-term and long-term efficacy. Compared with surgery, it is minimally invasive with fewer complications, and patients recover faster. In addition, because the mucosal layer is preserved, even if esophageal perforation occurs during the procedure, the tunnel opening can be easily closed to seal the perforation. Therefore, peroral endoscopic myotomy (POEM) is currently the best choice for the treatment of achalasia.

III. Introduction to ERCP Performed in the Endoscopy Room

For patients with common bile duct stones or pancreatic duct stones who do not want open surgery, what endoscopic treatments are available?

Endoscopic retrograde cholangiopancreatography (ERCP) for diagnosis and treatment has been performed in China for nearly 30 years. The Department of Digestive Endoscopy of the First Affiliated Hospital of Dalian Medical University began this technique in 2000 and has reached an advanced domestic level; it is the treatment of first choice for patients with common bile duct stones. Over the past 10-plus years, several thousand patients have received ERCP at our hospital for biliary and pancreatic diseases, which not only spares patients the suffering of open surgery but also shortens hospital stays and greatly reduces their medical costs.

For patients with advanced bile duct cancer or pancreatic cancer who cannot undergo surgery, what methods does the endoscopy room have?

For patients with obstructive jaundice caused by bile duct cancer or pancreatic duct cancer who cannot tolerate surgery, biliary or pancreatic duct stents can be placed during ERCP, thereby relieving the obstruction of the pancreatic duct and bile duct, ensuring smooth drainage of pancreatic juice and bile, alleviating the patient's symptoms, and improving liver and pancreatic function.

IV. Endoscopic Ultrasonography

Endoscopic ultrasonography involves mounting an ultrasound probe at the front end of the endoscope, directly observing the morphology inside the patient's body cavity through the endoscope while performing real-time ultrasound scanning, to obtain ultrasound images of the layered structure of the digestive tract wall and of adjacent organs outside the wall.

Endoscopic ultrasonography is of decisive significance for the assessment and differential diagnosis of protruding lesions in the esophagus, stomach, and duodenum; through the examination, the type of lesion the patient has can be determined. Combined with its sonographic features, it can diagnose stromal tumors, lipomas, intramural cysts, and duodenal Brunner's gland hyperplasia; it also helps to differentiate aberrant pancreas, polyps, and early cancer, and can identify venous aneurysms so as to avoid massive bleeding caused by blind biopsy.

For preoperative TN staging of esophageal cancer and gastric cancer, endoscopic ultrasonography is clearly superior to CT and other examinations, helping physicians judge the resectability of the tumor before surgery and formulate a reasonable surgical plan; it also has extremely high accuracy in the staging of esophageal cancer radiotherapy and gastric malignant lymphoma and in observing the efficacy of chemotherapy. In addition, it is quite valuable for the differentiation and assessment of benign and malignant ulcers and hypertrophic diseases of the gastric mucosa.

Endoscopic ultrasonography has greatly improved pancreatic ultrasound images and raised the diagnostic level for pancreatic diseases. It is recognized as the most sensitive method for diagnosing small pancreatic cancer (<2 cm), and is not inferior to CT in staging pancreatic cancer and judging resectability; it is the best choice for detecting, searching for, and localizing small pancreatic endocrine tumors. In addition, endoscopic ultrasonography can be used for the localization and staging of duodenal papillary carcinoma; for distal common bile duct obstruction, it helps in choosing between surgical treatment and endoscopic interventional treatment.

Endoscopic ultrasonography is currently developing rapidly, and its fields of application are steadily expanding. For example, endoscopic ultrasound-guided fine-needle aspiration biopsy has been applied to the staging of lung cancer and the characterization of mediastinal masses and lymph nodes as well as masses around the gastrointestinal tract. Meanwhile, endoscopic ultrasonography has also begun to be used in treatment: EUS-guided celiac plexus block can be used for intractable abdominal pain in patients with pancreatic cancer and chronic pancreatitis; EUS-guided drainage of pancreatic cysts and abscesses is also being promoted and applied, and new techniques such as EUS-guided radiofrequency ablation for pancreatic cancer and other gastrointestinal tumors are being gradually explored. In short, with the renewal of equipment, the accumulation of experience, and the continuous improvement of techniques, endoscopic ultrasonography will have even broader application prospects.