Interventional Endoscopy Gastrointestinal Procedures

• Cyanoacrylate Treatment of Gastric Varices
• Magnification endoscopy and chromoscopy
• Argon Plasma Coagulation (APC)
• Endoscopic Mucosal Resection (EMR)
• Resection of large colorectal polyps
• Zenker's diverticulum septotomy
• Endoclipping
• Endolooping
• Anti-reflux procedures

Cyanoacrylate Treatment of Gastric Varices

Read our Procedure Profile on Cyanoacrylate Treatment of Gastric Varices.
Variceal bleeding is a devastating complication of portal hypertension. One third of patients die after the first attack of variceal bleeding. Many factors contribute to the high mortality and morbidity. Bleeding not only precipitates hemodynamic instability, but also necessitates aggressive fluid resuscitation and blood product replacement that can result in multiple secondary complications such as ascites, jaundice, renal failure, and infection. Worsening of compromised hepatic function, coagulopathy, and encephalopathy add to the poor prognosis.

Gastro-esophageal varices develop in 50% to 60% of cirrhotic patients and approximately one-third of them will experience an episode of variceal hemorrhage within two years of varices diagnosis. Bleeding gastric varices account for roughly 10% to 15% of all variceal bleeds.

Cyanoacrylate is a liquid substance with the consistency of water that transforms into a solid state when added to a physiological medium such as blood. When instilled into a varix using the standard method of intravariceal injection, the glue undergoes an instantaneous polymerization reaction and hardens to a rock hard substance, thereby plugging the lumen of the varix. This enables rapid hemostasis of active bleeding and prevents rebleeding.

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Magnification endoscopy and chromoscopy

Magnification endoscopy is performed with a special "zoom" endoscope to identify surface irregularities of the gastrointestinal tract. Chromoscopy using various contrast dyes enhances the detection of higher-risk tissue. Both are applied in the upper and lower GI tract to improve the detection of premalignant and malignant lesions.


100x magnified view of a tongue of Barrett's esophagus. Area of flattened villous mucosa on left margin represents high grade dysplasia.

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Argon Plasma Coagulation (APC)

APC is a non-contact thermal device that is used to treat diffuse bleeding from a tumor or vascular lesions such as arteriovenous malformations or radiation-induced telangiectasias. APC is also used to treat refractory strictures, refractory varices, and Barrett's esophagus with dysplasia.


APC of multiple vascular ecstatic lesions in the stomach antrum (GAVE syndrome).


Non-contact method of coagulation using the APC probe.

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Endoscopic Mucosal Resection (EMR)

Read our Procedure Profile on Endoscopic Mucosectomy.
EMR refers to the radical removal of the mucosal layer of the gastrointestinal tract. It is used for the curative treatment of "early" cancers of the esophagus, stomach, and colon as well as Barrett's esophagus associated with high-grade dysplasia. EMR is used in the colon for the removal of flat polyps.


Early cancer invading the mucosa before EMR.


Appearance after EMR. The mucosa and submucosa has been completely excised.

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Resection of large colorectal polyps

Large polyps are removed in a piecemeal fashion by snare mucosal resection. The resection margins and remnant adenomatous tissue is fulgurated with APC.


4 cm giant "carpet" polyp


Appearance after resection
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Zenker's diverticulum septotomy

A needle knife is used to incise the septum of a Zenker's diverticulum (pharyngoesophageal pulsion diverticulum) to relieve dysphagia.


View of Zenker's diverticulum


After septotomy (NGT/nasogastric tube)

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Endoclipping

Endoclips are used to achieve hemostasis of bleeding vessels (ulcer, AVM, post-polypectomy). The mechanism of hemostasis is mechanical, analogous to surgical legation. Clips are also used to close tissue defects, fistulas, and small perforations.


Clipping of a bleeding vessel.

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Endolooping

Endoloops are legating devices that are applied to the base of a lesion to obstruct its blood supply. Lesions that are treated with endoloops include thick-stalked polyp (to prevent post-polypectomy bleeding), large polypoid varices (e.g., fundal varices in the stomach), and submucosal tumors


Endolooping of a thick-stalked poly.

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Anti-reflux procedures

Read our Procedure Profile on GERD.
Interventional treatments for GERD have emerged as an alternative to chronic medical treatment and - in selected cases - laparoscopic fundoplication. The goal of endoscopic therapy is to "tighten" the lower esophageal sphincter (LES) valve to reduce reflux. A new endoscopic treatment involves the implantation of an expandable prosthetic device into the submucosal space to enhance the function of the compromised LES (Gatekeeper reflux repair system).
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Paul May & Frank Stein Interventional Endoscopy Center

The Paul May & Frank Stein Interventional Endoscopy Center in San Francisco features some of the top-rated gastrointestinal disease doctors and interventional endoscopy specialists in the San Francisco Bay Area, Marin county and Northern California who use the most successful non-surgical treatment options available.


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