Polypectomy
Polyps are growths that mostly develop in the mucosa (inner lining) of the gastrointestinal tract, most commonly found in the colon, and are mostly benign. There is a possibility that a benign polyp can evolve into a malignant one, and this process can take months or even years.
Preventive colonoscopy, which is recommended for the general population starting at age 50, aims at the early detection of polyps and precancerous lesions, and their removal.
There are different types of polyps, with some having a stalk, called pedunculated, others being simple lumps (sessile), and others being almost flat.
Histologically, polyps can be classified into:
- Adenomatous Polyps: These are the most common type of polyps in the colon and are considered precancerous, meaning they have the potential to develop into colon cancer over time. Polyps can cause symptoms like mild pain, bloating, and small to larger bleeds. The likelihood of cancer developing in a polyp increases with its size, and the type of adenoma (tubular, villous, mixed) also plays a role.
- Hyperplastic Polyps: These are quite common, usually small in size, flat, pale, and do not develop into cancer. They are often found in the lower part of the colon.
- Inflammatory Polyps: These are associated with conditions like ulcerative colitis and Crohn’s disease. They are usually not precancerous.
- There are also rarer types of colon polyps, such as hamartomatous polyps, which occur as part of hereditary syndromes that follow an autosomal dominant inheritance pattern.
Before performing a polypectomy, temporary discontinuation of certain medications such as anticoagulants may be required. For colon polyps, the patient needs to follow a special diet a few days before the procedure and undergo bowel preparation for the colonoscopy the day before. Proper bowel cleaning is essential as it reduces the duration of the procedure, improves the examiner’s visibility, and drastically reduces the risk of complications.
At our clinic, we use carbon dioxide instead of atmospheric air for gastrointestinal distention, which is absorbed quickly by the intestinal walls and exhaled, minimizing discomfort after the procedure.
Polypectomy is an endoscopic procedure in which polyps are removed from the gastrointestinal tract. Depending on the size, location, and morphology of the polyps, different techniques may be applied, such as removal with a biopsy forceps, cold snare polypectomy, and hot snare polypectomy with diathermy.
The snare is a special tool placed through the endoscope channel, positioned as a loop at the base of the polyp, and used to cut and simultaneously cauterize the removal site, reducing the risk of bleeding.
The removed polyps are sent to the laboratory for histological examination to determine whether they are benign, precancerous, or cancerous.
In complex cases that may involve polyp characteristics or the patient’s medical history, polypectomy may need to be performed in a hospital setting. Our clinic collaborates with a large private hospital in Athens, where endoscopic procedures are carried out by our medical staff or selected scientific collaborators.
Rarely, performing the procedure under sedation may lead to cardiopulmonary complications such as arrhythmias or respiratory suppression, especially in patients with pre-existing heart disease or respiratory issues. Bleeding is a common endoscopic complication and is usually addressed with local injection of special medications or by placing hemostatic clips.
An even rarer complication is perforation, where a small hole is created in the colon during polypectomy. This is treated endoscopically or surgically.
Most polyps removed during endoscopy are small in size, so patients can usually eat freely and resume daily activities a few hours after the procedure. In special cases, such as multiple polyps, large polyps, or patients on medication (e.g., anticoagulants), detailed instructions will be provided by the doctor.
Endoscopic Gastrostomy
Endoscopic gastrostomy, or more specifically, percutaneous endoscopic gastrostomy (PEG), is a procedure in which a feeding tube (gastrostomy tube) is placed directly into the stomach through the abdominal wall.
Through this tube, it is possible to provide nutrition and/or administer medications in cases where the oral route cannot be used for an extended period due to various medical conditions.
- Neurological diseases, such as stroke, ALS (Amyotrophic Lateral Sclerosis), or Parkinson’s disease.
- Malignancy of the head and neck, such as cancer of the mouth, pharynx, or esophagus, leading to dysphagia or complete inability to take food orally due to the disease or treatment (e.g., radiotherapy).
- Chronic cachexia, as seen in patients with chronic conditions such as advanced heart failure, chronic obstructive pulmonary disease (COPD), or cancer, who have difficulty maintaining nutrition orally.
- In cases where drainage (emptying) of fluids from the stomach is required due to obstruction in the lower digestive tract (duodenum, small intestine, colon), such as from malignant tumors.
The procedure is carried out in a hospital setting under sedation combined with local anesthesia. A gastroscope, which is a thin, flexible tube with a camera and light, is inserted through the mouth and advanced into the stomach. The doctor uses the endoscope (gastroscope) to locate the appropriate area in the stomach’s inner wall and the abdominal wall for tube placement. After determining the correct site, the feeding tube is placed under strict sterile conditions.
After the procedure, the patient’s vital signs are monitored for a few hours to ensure there are no complications. The doctor will inform the patient and those responsible for their care about the proper function and care of the feeding tube and the skin around it, thus reducing the risk of complications and dysfunction of the gastrostomy.
Esophageal Variceal Ligation
Esophageal varices are dilated veins along the esophagus, particularly affecting the lower third. They are the result of increased pressure in the venous circulation of the liver (portal hypertension). Esophageal varices require frequent monitoring and treatment because if they rupture, they can be life-threatening due to severe bleeding.
Common causes of portal hypertension leading to the formation of esophageal and/or gastric varices include liver cirrhosis, thrombosis in the portal or splenic veins, severe heart failure, external pressure on the portal vein from tumors, or other rare liver diseases.
The most reliable method for diagnosing esophageal and gastric varices is endoscopy, which allows direct visual identification and assessment of the varices. In some cases, endoscopic ultrasound may also be useful.
Treatment depends on the size of the varices and includes:
- Endoscopic Treatment:
a) Placement of elastic bands (Band Ligation) that “strangle” the esophageal varices.
b) Injection of sclerosing agents into the gastric varices to reduce the risk of bleeding.
- Pharmacological Treatment: Beta-blockers such as carvedilol.
- In more complex cases, hospital-based treatments are required, such as the placement of TIPS (Transjugular Intrahepatic Portosystemic Shunt), liver transplantation, and other interventions.
Placement of Endoprostheses in the Digestive Tract
The placement of endoprostheses or stents in the digestive system is a technique used to maintain or restore the patency of the digestive tract in cases of narrowing or obstruction. These strictures can be either benign or malignant.
Malignant Strictures: Esophageal, stomach, pancreas, or colon cancer.
Benign Strictures: Inflammatory bowel diseases (e.g., Crohn’s disease), scar tissue from surgeries or radiation therapy.
Depending on the location of the stricture, an endoscopy (such as gastroscopy, colonoscopy, or endoscopic retrograde cholangiopancreatography (ERCP)) is performed to identify the exact site of the stricture. The stent is then placed through the endoscope into the narrowed area. The stent can be self-expanding or require balloon dilation.
- Metal Stents: Self-expanding metal stents (SEMS) are mainly used for malignant strictures.
- Plastic Stents: Typically used for benign strictures or temporarily for fluid drainage.
- Coated Stents: Coated with material that prevents tissue ingrowth into the stent, used to avoid blockage from tissue.
Potential complications include the stent shifting from its initial position or becoming obstructed by food or tissue growth. During the procedure, there is a risk of perforation during stent placement or bleeding during or after the procedure.
After the procedure, the correct placement of the stent and potential complications are evaluated through endoscopic or radiological monitoring. In some cases, special nutrition may be required for a few days after the stent placement or short-term hospitalization may be necessary.
Dilation of Digestive Tract Strictures
Benign strictures of the digestive system are narrowings of the digestive tract that are not caused by cancer or malignant tumors. These strictures can occur in various parts of the digestive system, such as the esophagus, stomach, small intestine, or large intestine.
- Inflammatory Diseases:
Gastroesophageal reflux disease (GERD)
Viral or fungal esophagitis
Crohn’s disease
Ulcerative colitis
- Surgical Procedures:
Scar tissue from previous surgeries in the digestive system.
- Radiation Therapy:
Mucosal damage from radiation therapy causing stenosis.
- Chemical and Physical Burns:
Ingestion of caustic substances.
Injuries from swallowing foreign bodies.
A stricture of the upper digestive tract may present with difficulty swallowing (dysphagia), pain while swallowing (odynophagia), vomiting, and weight loss.
A stricture of the lower digestive tract may present with alternating diarrhea and constipation, bloating, abdominal pain, constipation, and weight loss.
The diagnosis of benign digestive strictures is usually made through endoscopies (gastroscopy and colonoscopy). In some cases, radiological examination is also required.
In some cases, medication such as proton pump inhibitors (PPIs) or corticosteroids may improve symptoms.
In other cases, endoscopic intervention is required, such as dilation of the stricture with a balloon or bougie. Another endoscopic method is the placement of a stent to maintain the patency of the digestive tract.
In cases where other treatments are ineffective, surgical removal of the strictured section may be necessary.
- Balloon dilation is a minimally invasive endoscopic procedure that helps expand the stricture, improving the passage of food and fluids through the digestive tract.
Balloon Dilation Procedure:
The patient needs to fast for several hours before the procedure. Sedation or anesthesia is administered, and an endoscopy is performed. An endoscope (a thin, flexible tube with a camera) is inserted through the mouth or anus (depending on the treatment area). The narrowed area is located via the endoscope.
A special catheter is inserted through the endoscope and placed at the site of the stricture. The balloon is inflated with air or fluid, applying pressure to the walls of the narrowed area. The pressure is maintained for a few minutes, causing dilation and opening of the stricture. The balloon is then deflated and removed. The doctor checks whether the area has been sufficiently opened and if patency has been restored. In some cases, the procedure may need to be repeated.
2.Bougie dilation is another method used to treat benign digestive tract strictures. In this procedure, bougies (narrow, straight tubes of varying diameters) are used to gradually widen the narrowed area of the digestive tract.
Bougie Dilation Procedure:
As with balloon dilation, the patient must fast for a few hours before the procedure. Sedation is given, and an endoscopy is performed to identify the exact location of the stricture. A bougie is inserted through the mouth or anus (depending on the location of the stricture) and advanced to the narrowed area. The bougie is carefully pushed through the stricture to gradually open it. Initially, a smaller-diameter bougie is used. As the stricture dilates, progressively larger bougies are used until the desired result is achieved.
After the procedure, the patient is monitored for any complications and can typically return to normal activities the following day. In some cases, special nutrition may be required for a period of time.
Endoscopic Treatment of Hemorrhoidal Disease
Hemorrhoids are enlarged veins in the anus and the lower part of the rectum, similar to varicose veins that appear in the legs. They occur when there is increased pressure on these veins, leading to their swelling.
Factors that can lead to the formation of hemorrhoids include chronic constipation, sedentary lifestyle, and pregnancy, which result in increased pressure in the abdominal area. Contributing factors include obesity and a diet low in fiber.
- First degree: Internal hemorrhoids that do not protrude outside the anus. They usually cause bleeding without prolapse.
- Second degree: Hemorrhoids protrude outside the anus during defecation but return inside automatically.
- Third degree: Hemorrhoids protrude outside the anus during defecation and must be manually repositioned.
- Fourth degree: Hemorrhoids are permanently prolapsed and cannot be repositioned inside the anus.
Symptoms may include painless bleeding during defecation (hematochezia), itching, and pain or discomfort in the anal area.
The diagnosis of hemorrhoids is usually made through a clinical examination. In some cases, it may be necessary to perform a proctoscopy or sigmoidoscopy to detect internal hemorrhoids.
Treatment includes:
- Conservative measures for first-degree hemorrhoids, such as increasing fiber intake, ensuring adequate fluid intake, and possibly using laxatives. Additionally, medication may be required, such as topical ointments, creams, or suppositories to relieve symptoms.
- Endoscopic treatment of second to fourth-degree hemorrhoids. This is a modern, minimally invasive method for treating hemorrhoids aimed at relieving symptoms and resolving the problem without the need for open surgery.
Various endoscopic techniques are used for the treatment of hemorrhoidal disease, such as:
1.Rubber Band Ligation (RBL): Elastic bands are used to isolate and stop the blood flow to the hemorrhoids, causing them to fall off after a few days.
2.Laser Hemorrhoidoplasty (LHP): Laser energy is used to shrink the hemorrhoids with minimal invasiveness and faster recovery.
The choice of the appropriate treatment depends on the severity of the hemorrhoids and the patient’s specific needs.
ERCP – Endoscopic Retrograde Cholangiopancreatography
Endoscopic Retrograde Cholangiopancreatography, or ERCP, is a specialized endoscopic procedure used for the diagnosis and treatment of conditions affecting the bile ducts, gallbladder, and pancreatic duct.
- Cholelithiasis – Gallstones in the bile ducts or pancreatic duct.
- Strictures of the bile ducts or pancreatic duct due to chronic pancreatitis or cancer.
- Cholangitis – Inflammation of the bile ducts.
- Pancreatitis – Inflammation of the pancreas.
- Benign or malignant tumors – Cancer of the bile duct, pancreas, or liver that leads to obstruction of the bile or pancreatic ducts
The procedure is conducted in a hospital setting. The patient must fast, and the examination is performed under anesthesia. A long, flexible tube with a camera and light at its end (an endoscope) is inserted through the mouth into the esophagus, then the stomach, and ultimately into the duodenum. A catheter is then inserted into the common bile duct or pancreatic duct through the papilla of Vater. A contrast medium is injected into the ducts, allowing for imaging of the bile and pancreatic ducts using X-rays. During the examination, problems such as stones in the bile ducts, strictures, tumors, or inflammation may be identified. Depending on the case, therapeutic interventions such as stone removal, stent placement, or dilation of strictures may be performed.
ERCP is an invasive medical procedure that carries certain risks and potential complications, such as pancreatitis (inflammation of the pancreas), bleeding, especially if strictures are dilated or stones are removed, and more rarely, perforation of the digestive system. After the procedure, patients are monitored for 24 hours.
Destruction of Gastrointestinal Angiectasias with Thermal Coagulation (APC)
Angiectasias are small, dilated blood vessels that can bleed, causing gastrointestinal bleeding. They are typically found in the colon but can occur in other areas of the digestive system. Bleeding may lead to serious issues, such as anemia, hematemesis (vomiting of blood), or hematochezia (rectal bleeding).
Thermal coagulation with APC (Argon Plasma Coagulation) is an endoscopic therapeutic method used to treat bleeding and destroy angiectasias in the gastrointestinal tract. This technique involves applying low-temperature argon plasma energy through an endoscope.
- Patient Preparation:
The patient must fast before the procedure.
Anesthesia is administered, and the patient’s vital signs are monitored. - Endoscopy:
The doctor inserts the endoscope through the mouth or anus, depending on where the bleeding or angiectasias are located in the digestive tract.
The endoscope is a long, flexible tube equipped with a camera and light, allowing the doctor to view the inside of the digestive tract on a monitor.
A special APC catheter is inserted through the endoscope.
This catheter releases argon gas, which ionizes and creates plasma when exposed to an electric current.
The argon plasma is applied to the bleeding area or angiectasia, causing tissue coagulation and stopping the bleeding. - Post-procedure Course
Patients usually recover quickly and can resume normal activities soon after the procedure.
Thermal coagulation with APC is a safe procedure with high success rates and minimal complications, such as:
Bowel perforation: Although rare, there is a risk of bowel perforation.
Secondary bleeding: Bleeding may occur after the procedure.
Destruction of Anal Warts
Anal warts are abnormal growths caused by the human papillomavirus (HPV), appearing around and inside the anus. They are a sexually transmitted infection. Their appearance ranges from small bumps (in the early stages) to several-centimeter-large growths in the anal area (in advanced or neglected stages).
If you notice any lumps on the external skin, you should visit a dermatologist – venereologist.
However, if you feel a lump inside the anus, you should immediately consult a gastroenterologist, who will recommend a proctoscopy.
Anal warts can be asymptomatic or cause the following symptoms:
- Itching or Irritation
- Bleeding, especially during bowel movements
- A feeling of a foreign body in the anal area
The diagnosis of anal warts is made by a doctor through:
- Clinical Examination: The doctor will examine the anal area for the presence of warts.
- Proctoscopy/Rectoscopy: An endoscopic procedure that allows examination of the interior of the anus and rectum.
- Biopsy: In some cases, a tissue sample may be taken to rule out high-grade dysplasia or cancer.
The treatment of anal warts depends on the size, number, and location of the warts.
If the warts are external on the skin and not inside the anus, the dermatologist-venereologist will treat them with topical medication, cryotherapy, or surgical removal.
If the warts are internal in the anus, the available treatments are either thermal coagulation with Argon (APC) or surgical excision.
Vaccination: HPV vaccination can significantly reduce the risk of infection with the types of the virus that cause warts and cancer.
Use of Condoms: Using condoms during sexual intercourse can reduce the risk of HPV transmission.
Regular Check-ups: Regular medical examinations and screenings can help with the early detection and treatment of warts.
