SAN ANTONIO – Colorectal cancer is the second-leading cancer killer among men and women in the u-s. A colonoscopy can spot and remove signs of cancer – which can show up as polyps. But sometimes these polyps are flat and very difficult to remove.
Trees, houses, barns – Ken Kurtz has filled the walls of his house with his own masterpieces
"I'm running out of places to put the paintings!" Ken Kurtz told Ivanhoe.
The 71-year-old took up painting 12 years ago when he retired.
"I was hooked!" said Kurtz.
But Ken almost had to put his hobby on hold when a diagnosis from his doctor wasn't so "picture-perfect". A routine colonoscopy showed Ken had a suspicious polyp that could be cancerous.
Once you know it's there," said Kurtz, "then you worry about it a little bit."
Most polyps can be easily removed, but Ken's was flat – like the one you see here. In prior years that meant cutting out two feet of his colon to take out the difficult polyp.
"You can imagine, taking out half of your intestine, large intestine, is a big operation, a major operation." Emre Gorgun, M.D., Department of Colorectal Surgery and Staff Surgeon at the Cleveland Clinic Department of Colorectal Surgery and Quality Improvement Officer told Ivanhoe.
But Cleveland Clinic surgeon Dr. Gorgun offered Ken a new option called ESD. During a colonoscopy, they place a solution under the lesion. Then they use special instruments to make small cuts and remove the flat polyp – while leaving the colon in-tact.
"Almost doing a surgery outside the body, we do a surgery inside of the body, inside of the colon." Dr. Gorgun said.
Ken's polyp was not cancerous. He's happy he avoided an unnecessary operation – and can get back to focusing on his art.
Another study by Dr. Gorgun shows only nine-percent of polyps that are removed are cancerous. That means most of the time a colon is removed, it's an unnecessary procedure. Doctor Gorgun says he hopes the e-s-d technique will prevent more patients from needlessly losing their colons.
BACKGROUND: Polyps can form in the colon because of unregulated mutations in genes that cause cells to continue growing, even when new cells are not needed. Generally, the larger the polyp, the greater the chance of it becoming cancerous. Flat polyps are five times as likely to become cancerous as regular polyps of similar size. A healthy diet, limited use of tobacco and physical activity can help prevent the growth of polyps; however, there are hereditary factors that are linked to polyp growth as well.
(Source: http://www.mayoclinic.org/diseases-conditions/colon-polyps/basics/causes/con-20031957, http://www.johnshopkinshealthalerts.com/reports/colon_cancer/3165-1.html, http://www.mayoclinic.org/diseases-conditions/colon-polyps/basics/risk-factors/con-20031957)
TREATMENT: Polyps are typically discovered during a colonoscopy, in which a small camera is guided through the intestine. In most cases, a polyp can be removed using biopsy forceps or a wire loop that cuts the polyp out. In extreme cases, a portion of the colon is removed (proctocolectomy).
(Source: http://www.medicinenet.com/colonoscopy/article.htm, http://www.medicinenet.com/colon_polyps/article.htm, http://www.mayoclinic.org/diseases-conditions/colon-polyps/basics/treatment/con-20031957,
NEW TECHNOLOGY: Developed in Japan in the mid 1990's, Endoscopic Submucosal Dissection, or ESD, was used for early stage gastrointestinal tumors. Now used to remove flat polyps in the colon, ESD first injects a solution under/into the polyp to cushion it. The solution should ideally be inexpensive, easily available, and nontoxic. Some examples of solutions include: saline, glycerol, and hyaluronic acid. An incision is then made around the polyp using specialized endoscopic knives such as a needle-knife. Bleeding and perforation of the colon are possible risks of ESD, however, the alternative may be a total proctocolectomy, even if the polyp is not found to be malignant.
(Source: http://www.medscape.com/viewarticle/780498, http://www.asge.org/assets/0/71312/71314/2B0F17E6-6E5E-4CAB-95F1-F9D9D4043520.pdf, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2712159/)
FOR MORE INFORMATION ON THIS REPORT, PLEASE CONTACT:
Caroline Auger
Public Relations
Cleveland Clinic
216.636.5874
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Emre Gorgun, M.D., Department of Colorectal Surgery and Staff Surgeon at the Cleveland Clinic Department of Colorectal Surgery and Quality Improvement Officer, discusses colon polyps and a new method of removing them.
Has the number of colon cancers increased?
Dr. Gorgun: We have been seeing more and more colon cancer patients lately. One of the reasons is more awareness as well as screening modalities are improved lately. And patients are more following directions and going to their primary medical doctors and primary physicians to get their colons checked out which is most of the time a colonoscopy, it's a screening colonoscopy. And these end up finding more cancers, and then patients get referred to us.
Is there a little controversy going on right now about colonoscopy, because it's kind of like breast cancer and mammograms? For example every five years or every ten years, or do you need to start when you're fifty, fifty five or sixty. Isn't there a little bit of the question now?
Dr. Gorgun: There's not so much actually if you follow the guidelines that are established by American College of Gastroenterologists and American Society of Colorectal Surgeons. The recommendation is still having a colonoscopy, screening colonoscopy, diagnostic colonoscopy at the age of fifty. So anyone who reaches that age should have one screening colonoscopy.
And so the colonoscopies are very good at finding polyps.
Dr. Gorgun: That's correct in most cases.
But there's a polyp that a lot of times is missed?
Dr. Gorgun: That's correct yes. The purpose of the screening colonoscopy is to find any colonic lesions. We call them polyps, or adenomas are some lesions that can grow in the colon. To find them not only find them also to destroy them to get rid of them. So that's the purpose of the screening colonoscopy.
And so traditionally how is that done with just the normal polyp?
Dr. Gorgun: At the time of the screening colonoscopy endoscopists looks for any abnormal lesions in the colon, any raised lesions that can be found in the colon inside. So that's traditionally how our endoscopists are doing their screening. And if there's any lesion that is abnormal, raised or is sticking out in the view then you know the goal is to take it out and remove it.
And how do they take it out?
Dr. Gorgun: Take it out usually means a loop of wire, a snare, placed through the colonoscopy channel and that it can be placed around the polyp and can be just used to cut off the polyp.
But not all these. Flat polyps -- Explain what a flat polyp is?
Dr. Gorgun: Sure. So there are different types of polyps actually as you may know. The easy ones are the ones that are raised from the colon or that they almost look like a mushroom. They can easily be identified and found and potentially even removed although they can be in different sizes, but most of the time the endoscopies can remove them and then the patients are pretty much cleared from these lesions. But there are some other polyps that, like you brought up, flat polyps. Flat polyps are not so easily to be detected on the screening colonoscopy because they can be hidden. They can be a little bit difficult to see. So in those circumstances there are different techniques to see them like chromo endoscopy using some dye spray or there are different modes in the colonoscopy devices like a different narrow band imaging we call it. You know a different light mode that can be switched on the scope itself. These mortalities can help us to determine these hidden lesions. So it's important.
Who would be finding this?
Dr. Gorgun: Endoscopists.
Are the endoscopists really trained to find these flat polyps?
Dr. Gorgun: That's correct. It is not very easy to find the flat polyp. Actually we did a study many years ago that the flat polyps can be missed in the United States since our eyes were not trained to recognize them. In Japan, Far East the endoscopists are more trained and their eyes are more used to recognize these flat polyps. So most of the time the polyps that are referred to us for surgeons are mostly raised easily recognizable lesions. However equally important is to recognize these flat polyps because they can turn into colon cancer as well. So the more and more we do these screening colonoscopies the more conscious we have to be more in terms of recognizing all types of polyps. I just want to raise an attention that recognizing flat polyps is as equally important as finding the raised polyps or more like, pedunculated polyps.
So why is it in Asia, do they have more instances of flat polyps?
Dr. Gorgun: This is a very good question. I think this is very much related to be able to recognize these lesions endoscopically and having trained eyes and skills. So in America endoscopists should be aware of the flat polyps and trained to recognize these flat polyps.
And are they just as dangerous or are there more instances of cancer?
Dr. Gorgun: I cannot say there are more but they can be as dangerous as regular polyps. So they need to be recognized, once they are recognized they need to be also removed. They need to be taken out of the colon.
But removing is a little bit harder.
Dr. Gorgun: Removing is definitely harder it requires some advanced skill. And we have been removing these flat polyps for a while now here at the Cleveland Clinic with various techniques. And this requires more advanced techniques in the sense of advance endoscopic maneuvers and procedures. So because it is not a raised polyp simply putting a wire loop around it is not that easy. So you need to make them or turn them into almost like a raised polyp and those require injection under the lesion or injection of a little solution underneath these polyps, and then that can help to raise them but still that it is not high enough, raised enough, to put a wire around them. And they are also inside of the colonoscopy going some small instruments, we call them dual knife or, colonoscopy knifes. Or, if you will, a scalpel that works through a colonoscopy that you can literally do inside of the colon some surgical procedures and literally make some incisions around these lesions and little by little make cuts and remove those lesions.
Now what is an ESD?
Dr. Gorgun: ESD is a procedure that helps to remove a flat polyp or polyps that are difficult to be removed with conventional "classical" techniques and excise pulling a wire around the polyp. So ESD enables us to remove difficult colon lesions that are hard to be removed by other conventional techniques.
What's that stand for?
Dr. Gorgun: It stands for Endoscopy Submucosal Dissection. That means there are a few steps that go into it. So first step is recognizing the lesion and then putting a solution underneath it which helps to raise the polyp from the surface.
What is the solution?
Dr. Gorgun: I use different types of solutions; it has to be little bit thicker, it has to be a little bit more viscous so it remains in the tissue otherwise it dissipates very quickly. I actually use some types of eye solutions that are very viscous and I dilute them with normal saline and then inject and place them under this colonic lesion. And after that step using special knifes, special techniques, special instruments that goes through the colonoscopy, almost doing the surgery inside the body within the intestine. We do the surgery inside of the body inside of the colon and make small incisions, small cuts around lesions and go underneath and undermine the lesion and cut through this lesion and ultimately remove the lesion. So if you will it's a surgery performed staying inside of the colon.
And so it's all no incisions?
Dr. Gorgun: No incision it's done through the colonoscopy it's done through the bottom end and no scar.
Since its flat is there more of a risk to damage the colon wall?
Dr. Gorgun: You brought up a very good question in terms of asking if there's more risk to hurt the colon. That's correct because it's more invasive in the sense of cutting through the colonic wall. There might be a little bit higher risk to make a full defect in the colonic wall but we do all of the techniques to prevent those but if we have any suspicion for a full thickness defect then we take additional precautionary steps – – and place from inside endoscopic metal clips to close the defect. So we have some tools to clip and close the defect from inside. Not only that, we also go laparoscopically from a small incision around the navel. Put a little camera, maybe one or two more small instruments, with tiny instruments and then look at the area from outside the colon. . And to make sure if that defect is really visible or not. And if there is a defect we can place couple of stitches from the outside so we can prevent making huge incisions.
Is there any difference in recovery time between a normal polyp and flat polyps removing them?
Dr. Gorgun: If you don't need to do the laparoscopy no, most patients can go same day. If there is a little bit more advanced technique there can be cases that we can keep them overnight just to be safe.
Is there anything that causes a flat polyp?
Dr. Gorgun: Yeah, they like a regular polyps there's no certain thing that really is known to us, to the best of our knowledge that is causing these but you know but they are just adenomas. And more like the polyps is just a genetic disposition.
Ken Kurtz do you remember him?
Dr. Gorgun: Yes, of course and he greatly benefited from this procedure.
Can you tell me a little bit? Does he have flat polyps?
Dr. Gorgun: Yes, he had flat polyps and these polyps were removed before but partially removed. So he was referred to me for basically for a colon resection, meaning for his large intestine to be removed. After reviewing the case I thought I could perform advanced endoscopy procedures some advance endoscopy techniques and potentially save his colon. And I think that's huge, especially with the new healthcare changes and the more screening colonoscopy are being done the more polyps are discovered. So we need to save more colons when feasible.
Why would they say he needs his colon taken out?
Dr. Gorgun: Any polyp, any abnormal tissue in the colon is not safe to leave it there. Unless it's proven otherwise you know they can be cancer. To prove that they are not cancer they need to be taken out. So with Ken it was the same scenario; he was sent for a bowel resection for having his bowel removed. But he has a great quality of life and he was enjoying his life. That would definitely put him at risk for some complications after surgery as well as would take him off his golf course for a couple of weeks for sure.
So did he have a malignant tumor, malignant polyp?
Dr. Gorgun: So that's a very good question. We did do a study about polyps that were not amenable for endoscopy removal, polyps that were thought to be not removable by endoscopy techniques, were sent to surgeons and we reviewed our results for over ten years period. And what we found was that out of these polyps that were thought to be benign but couldn't be technically removed the final pathology was benign ninety one percent of the time. That means only nine percent of these patients had malignant cancer. In other words that means that ninety one percent of the time we took colons out for a benign lesion which was, if you will, overtreatment. So if a polyp can be removed with more advanced endoscopy techniques we could prevent at least ninety one percent of the time potentially patients that would go to colon resection.
And that's ninety one percent of the time of people who are living without their colon, what would that mean for them?
Dr. Gorgun: Most of the time removal of colon is segmental -- part of the colon is removed not necessarily the entire colon. They can still have okay bowel functions but you can imagine taking half of the intestine, large intestine is a big operation, it's a major operation. And patients can be at risk for connection site leaks after surgery, I mean not that we don't do these operations very often. Of course when we have to do them we need to, but if there are other advanced techniques to prevent us from respecting the bowel that's what we need to do. And that's our goal to save more colons as possible.
Do you think removing the bowel is going to become less and less?
Dr. Gorgun: I think so and that should be our physicians, endoscopists, surgeons, and scientists' goal to achieve. You know that with the refinements of instruments, colonoscopy devices even new platforms and in the intestine we will be able to do more surgeries inside, staying inside of the intestine and doing more surgeries inside of the intestine. We will not need to remove the whole organ to be able to treat diseases. So definitely this is going to be happening.
And Ken's case it seems to be really extreme to remove his bowel when you didn't know whether there was a real problem or not smart.
Dr. Gorgun: That's exactly correct, yes. But if someone is not capable of removing a lesion with the advanced techniques then there is no other option other than going to the next step. So that's what I tell my patients; starting from less invasive to go more invasive. But that's an advantage of being a colorectal surgeon; I can do all these procedures in the operating rooms. I start out with endoscopy techniques, I start with endoscopy sub mucosal dissection if there is some limitations there I can go to the laparoscopy, if there's a hole I can repair it laparoscopically. But if things are even more serious than that like nine percent of the time they can be cancer, if anything like that is suspected then I can also go and do the operation taking out the colon as well at the same time in the operating room.