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Third Space Endoscopy and Advanced Endoscopic Resection Techniques in the Gastrointestinal Tract

Dennis Yang, MD, discusses third space endoscopy and its role in the management of various GI disorders. He provides information on the role of POEM in the management of esophageal motility disorders. He discusses the role of advanced endoscopic resection techniques in the treatment of lesions in the esophagus and he examines the role of advanced endoscopic resection techniques in the treatment of lesions in the colon.
Third Space Endoscopy and Advanced Endoscopic Resection Techniques in the Gastrointestinal Tract
Dennis Yang, MD
Dennis Yang, MD is an Assistant Professor of Medicine, Division of Gastroenterology, Hepatology and Nutrition. 

Learn more about Dennis Yang, MD

Melanie Cole, MS (Host):   The capabilities of interventional gastrointestinal endoscopy have significantly increased over the past several decades. Welcome. This is UF Health Medcast with UF Health Shands Hospital. I'm Melanie Cole and today we’re examining third space endoscopy and it’s role in the management of various GI disorders. We’ll talk about the role of POEM, peroral endoscopic myotomy, and the management of esophageal motility disorders. We’re also discussing the role of advanced endoscopic resection techniques in the treatment of lesions in the esophagus and in the colon. Joining me is Dr. Dennis Yang. He’s an assistant professor of medicine at the University of Florida Division of Gastroenterology, Hepatology, and Nutrition and practices at UF Health Shands Hospital. Dr. Yang, it’s a pleasure to have you join us today. Let’s start by explaining a little bit about achalasia and spastic esophageal disorders not responding to medical therapies.

Dennis Yang, MD (Guest):   Achalasia and spastic esophageal disorders are often difficult to treat medically. Most of these patients with time do not respond to medical therapies. Most of their symptoms can include chest pain, difficult swallowing, sometimes regurgitation and vomiting. Eventually over time most of these patients will end up requiring some type of interventional procedure.

Host:  Well then tell us a little bit about peroral endoscopic myotomy or POEM. What's the history of this?

Dr. Yang:   Traditionally in the past, the management of achalasia has revolved around two main procedures. One of them is endoscopic pneumatic balloon dilation. The other one—the more definitive and perhaps longer treatment plan—involved conventional surgery or Heller myotomy. Peroral endoscopic myotomy or POEM is a procedure that was developed approximately a decade ago now, introduced into clinical practice. The whole idea is that it’s a minimally invasive procedure that is performed endoscopically that can obtain the similar results by mimicking what the surgeons can do. The advantage of this procedure is that it’s minimally invasive with a faster recovery time when compared to conventional surgery.

Host:  Are there any concerns, Dr. Yang, for the feasibility, safety, efficacy of POEM in patients who have undergone previous endoscopic techniques or surgical treatments?

Dr. Yang:   There's been an increasing and amassing literature on the role of POEM for these difficult to treat patients. We are more and more often seeing patients with previously failed other therapies including even surgical myotomy. Unfortunately the evidence so far appears to be that POEM is effective in these patients. While the response rate might not be as high as somebody who has not previously undergone treatment such as Heller myotomy, their response is still fairly high. More than approximately 80 to 85% of these patients tend to respond even after previously failed treatment. They’ve also looked at now how POEM compares with other treatment including the ones I previously mentioned, like pneumatic balloon dilation and surgical myotomy for these patients with previously failed treatment. It appears to compare very favorably.

Host:  Well thank you for that answer. So as we’re discussing the role of advanced endoscopic resection techniques in the treatment of lesions in the colon and in the esophagus and since many of the gastrointestinal cancers are diagnosed at an advanced stage, Dr. Yang do these things of resection techniques also have the advantage of providing accurate local staging of the disease compared with ablative techniques? Speak about all of these resection techniques and why you feel they're advantageous.

Dr. Yang:   We can start first by focusing on the esophagus. So in the western hemisphere, Barret’s esophagus—which is a condition associated with chronic reflux—has been fairly common in our population. Barret’s esophagus is a precancerous condition that predisposes people to esophageal adenocarcinoma. Esophageal adenocarcinoma requires surgical management. The problem with this approach is obviously the significant morbidity and mortality associated with surgery. So in recent years there’s been an increasing shift towards more minimally invasive approaches such as endoscopic mucosal resection and even more recently endoscopic submucosal dissection. Both of these procedures which we commonly perform at UF Health Shands Hospital. The idea is that these procedures can potentially be curative not only for advanced precancerous lesions but even be curative for early cancerous lesions that previously would have required the surgery.

In addition to that, as you mentioned, these procedures can also provide more accurate histological staging compared to your standard biopsy type of procedures. So overall, the procedure can be both functioned as a staging procedure, but it also provides curative intent in the majority of these patients and then therefore obviating the need of definitive surgery.

So now moving on to the colon, recent data from the United States has shown that the referral rate for surgery for benign and early cancerous lesions in the colon continuous to rise in spite of the evidence showing the increasing morbidity, cost, as well as mortality associated with surgery for these lesions. So similar to the diseases in the esophagus, lesions in the colon whether these are non-malignant benign colorectal polyps or early cancerous lesions in the colon, there's been an ongoing trend and shift towards endoscopic therapy. These therapies most commonly involved, again, endoscopic mucosal resection or EMR or endoscopic submucosal director—or ESD—which again we commonly perform at UF Health Shands Hospital. Both of these type of procedures have shown to be associated with very high efficacy rates in terms of curative intent and also with improved adverse events when compared to surgery and at a lower cost and faster patient recovery. Most of these procedures when performed correctly can eliminate the need for surgery in these patients.

Host:  Wow, that’s so interesting. Dr. Yang, tell us about the learning curve for advanced endoscopic resection techniques and POEM. Since this is relatively new, what are you seeing as far as other providers learning these techniques?

Dr. Yang:   These procedures are advanced endoscopic resection techniques and advanced techniques in third space endoscopy. Therefore the learning curve has been relatively steep, particularly due to the lack of adequate training opportunities in the western hemisphere as opposed to in Asia where these procedures were initially developed. However, over recent years we have seen significant change and increase in the availability of resources for practicing physicians interested in these techniques. For example, as compared to previous years now we have even dedicated books on third space endoscopy and advanced endoscopy, which we recently published and it’s currently available. In addition to this at UF Health Shands Hospital every year we also offer a dedicated course regarding these advanced techniques for practicing physicians. These courses have both the purpose of serving as an exposure course but also allows hands on practice for these physicians with experts in this field from around the world.

Host:  Wow. I'm so glad that I asked you that question. So as we conclude, Dr. Yang, tell other providers what you’d like them to know about third space endoscopy, advanced endoscopic resection techniques, POEM, EMR, and when you feel it’s important that they refer to the specialists at UF Health Shands Hospital.

Dr. Yang: Well, we are always receiving referrals here at UF Health Shands Hospital with open arms starting with achalasia spastic esophageal disorders. Any of these patients can be referred to us. We have a multidisciplinary group that involves specialists and gastrointestinal motility disorders, advanced endoscopic who perform these procedures, and we work in conjunction with the surgeons as well to kind of develop the best treatment strategy for each individual patient. This more often than not involve some of these techniques such as poem given the excellent outcomes that we have achieved here at the UF Health Shands Hospital and also the long term outcomes that we have witnessed across the world. Similarly, again, all patients with colorectal lesions such as polyps and so forth that are detected on routine colonoscopies and surveillance should be referred to a specialized center such as ours at UF Health Shands Hospital in which we can then evaluate the patient to determine if they're eligible and a candidate for one of these techniques such as endoscopic mucosal resection or endoscopic submucosal dissection. Because if this is the case more often than not we are able to resect these lesions endoscopically. These are procedures that are performed on an outpatient basis. The patient’s able to go home the same day without requiring any hospitalization. Because these procedures are associated with good efficacy and low adverse events, they should always be considered the first line before referring a patient to definitive surgery.

Host:  Thank you so much Dr. Yang. What a fascinating topic. Thank you for joining us and sharing your incredible expertise. That concludes today’s episode of UF Health Med Edcast with UF Health Shands Hospital. To learn more about this and other healthcare topics at UF Health Shands Hospital, please visit to get connected with one of our providers. Please remember to subscribe, rate, and review this podcast and all the other UF Health Shands Hospital podcasts. For more health tips and updates on the latest medical advancements and breakthroughs, please follow us on your social channels. I'm Melanie Cole.