Practical Gastrointestinal Endoscopy

THERAPEUTIC UPPER ENDOSCOPY 67
Conservative management is more likely to be appropriate when
the perforation is in the neck; because the mediastinum is not
contaminated, local surgical drainage can be performed simply
when necessary. Perforation through a tumor can be treated immediately
with a covered stent, if the lumen can be found, and if
surgical cure is not possible.
GASTRIC AND DUODENAL STENOSES
Functionally significant stenoses may occur in the stomach or
duodenum as a result of disease (tumors and ulcers) and following
surgical intervention (e.g. hiatus hernia repair, gastroenterostomy,
pyloroplasty and gastroplasty). Balloon dilation of
stenosed surgical stomas is usually effective (except in the case of
banded gastroplasty with a rigid silicone ring). Pyloroduodenal
stenosis caused by ulceration can be relieved by balloon dilation,
but recurrence is common. Expandable stents are being used
with remarkably good effect in patients with malignant stenosis
of thestomach and duodenum.
GASTRIC AND DUODENAL POLYPS AND TUMORS
Endoscopic polypectomy is used very frequently in the colon,
and many of the techniques (see Chapter 7) can be applied in
the stomach and duodenum. Polyps are much less common in
the stomach and duodenum than in the colon, and are rare in
the esophagus. Many of these polyps are sessile, and some are
largely submucosal, making endoscopic treatment more difficult
and hazardous. The possibility of a transmural lesion should be
considered, and endoscopic ultrasonography may be helpful in
making a treatment decision; surgical(or laparoscopic) resection
may be safer. Injecting the base of sessile gastric and duodenal
polyps with epinephrine (adrenaline; 1·:·10·000) may make removal
easier, and may reduce the risk of bleeding. Some endoscopists
use detachable loops for the same purpose.
Endoscopic mucosal resection (EMR)has been developed in Japan
for removal of sessile lesions up to 2·cm or more in diameter. The
lesion is raised up by injecting a cushion of saline/epinephrine,
and then sucked into a special transparent plastic cap attached to
the tip of the endoscope. The lesion is then resected with a snare
loop incorporated in the cap (Fig. 5.7, see also Fig. 7.43).
Snare diathermy techniques can be used also to obtain large
biopsy specimens when the gastric mucosa appears thickened,
and when standard biopsy techniques have failed to provide a
diagnosis.
Gastric polypectomy, EMR and snare-loop biopsy techniques
can cause bleeding and perforation. They also leave an ulcer; it is
wise to prescribe acid-suppressant medication for a few weeks.
Fig. 5.7–Endoscopic mucosal
resection. (a) Inject a saline cushion
below the lesion. (b) Suck the
lesion into the transparent cap.
(c) Snare and resect the lesion.
(a)
(b)
(c)