Endoscopic submucosal dissection

ESD is a procedure which is already being used in the UK and across the world to remove lesions which are found in the bowel.

Abnormalities or lesions in the bowel can be cancerous or have a high risk of becoming cancerous, or they can be harmless (benign). Treatment usually involves removing the lesion. This can be done either via a surgical operation or via a camera which is inserted through the anus to view the abnormal area. In ESD, the abnormal area or lesion is removed along with a small area of normal tissue surrounding the lesion. If the area surrounding the lesion, when looked at under a microscope, is found to be clear of abnormal cells this is called a clear margin. If we find that there is a clear margin then there is a reduced risk of the abnormal lesion returning or recurring in the same area.

You will find some more detailed information about the potential benefits of the procedure, the procedure itself and the risks and alternatives in this booklet. Please do ask our team if there is anything which is not clear or which you would like more information about.

ESD is a procedure which is already being used in the UK and across the world to remove lesions which are found in the bowel.

Abnormalities or lesions in the bowel can be cancerous or have a high risk of becoming cancerous, or they can be harmless (benign). Treatment usually involves removing the lesion. This can be done either via a surgical operation or via a camera which is inserted through the anus to view the abnormal area. In ESD, the abnormal area or lesion is removed along with a small area of normal tissue surrounding the lesion. If the area surrounding the lesion, when looked at under a microscope, is found to be clear of abnormal cells this is called a clear margin. If we find that there is a clear margin then there is a reduced risk of the abnormal lesion returning or recurring in the same area.

You will find some more detailed information about the potential benefits of the procedure, the procedure itself and the risks and alternatives in this booklet. Please do ask our team if there is anything which is not clear or which you would like more information about.

In some people changes occur in the cells lining the colon. These changes can form lesions or polyps where there are many abnormal cells. In time, in some of these lesions in some people, the cells can change further and become pre- cancerous or cancerous.

When doctors perform a procedure called a colonoscopy, where a camera is inserted into your bowel or colon through your anus, they are able to see these lesions. By examining them carefully through the endoscope the doctors are often able to tell which of these lesions should be removed because they are pre-cancerous or cancerous lesions.

Colonic lesions are removed to stop them spreading elsewhere in the body. We aim to remove the cells with an area of normal cells around them (a resection margin) as this reduces the risk of the lesion coming back or spreading elsewhere. Following the procedure the lesion is sent to the histopathology laboratory for examination. If the lesion has been removed in a single piece (an en bloc resection), rather than several small pieces, it is easier both to examine under the microscope and to determine the risk of lesions coming back.

Patients being considered for ESD will have had a colonoscopy either at University College Hospital or at another hospital which has found a lesion that would be most suitable to be removed by ESD. The doctor or nurse performing this initial procedure will take photos and sometimes small biopsies of the lesion. These will then be discussed in something called an MDT (multidisciplinary team) meeting where they review the photographs and the biopsies (if taken) to make a decision if an ESD will be the best procedure for you. You will then meet one of the doctors who will perform the ESD procedure in clinic to discuss more about the procedure.

An endoscope is a tube with a camera on the tip that is designed to look at, and perform procedures within, the digestive system.

During the procedure, you will first be given some sedation through a drip or cannula in your arm. Although this is not a full general anaesthetic it will make you sleepy and relaxed. The endoscope (with some lubricating jelly) is then passed through your anus into your large bowel or colon. Once the doctor has identified the lesion they will re-examine it to make sure that it is suitable to be removed by ESD. The doctor will then use a needle that is inserted through the endoscope to inject some fluid around the lesion. This fluid helps to separate the abnormal tissue from the normal tissue around it.

A small device is used to cut around the lesion. The doctor will separate the abnormal area from the normal area and remove the abnormal cells or lesion. This is done quite slowly and the device can also be used to stop any bleeding while the procedure is ongoing. You should not feel any pain or discomfort from the tissue being cut away. The abnormal lesion is then removed from the bowel with the endoscope and sent to the laboratory to be looked at under the microscope.

Sometimes very small clips are also used after the procedure to stop any extra bleeding or to hold together some of the normal tissue. These will fall off naturally in time and be passed in your bowel movements. As they are so small it is unlikely you will be able to see them when they pass through.

Usually the procedure will take 1-2 hours. However the amount of time can be quite variable and will depend on the size of the abnormal lesion and where it is located in your bowel.

It is very important that you are fully aware of the benefits and risks of having ESD. All procedures that are carried out with an Endoscopy carry some degree of risk:

• Bleeding

  Around 1 in 29 people may experience bleeding after the procedure.

  If this happens, you may need to return to hospital for further treatment, such as another endoscopy to stop the bleeding or, in some cases, a blood transfusion.

• Perforation (a tear in the bowel wall)

  This happens in about 1 in 40 people.

  If this occurs during the procedure, the tear can usually be closed immediately using clips deployed through the endoscope. You will need to stay in hospital for a few days and receive antibiotic treatment.

  In a small number of cases (about 1 in 66), surgery may be needed if the tear cannot be managed with clips and medication alone.

There are other treatment options available. These include:

• Surgical operations to remove the section of the bowel where the lesion is located.
• Attempts to remove the lesion by other endoscopic methods (including by endoscopic mucosal resection).
• Doing nothing.

However, these interventions may not be suitable for you. If you have any questions about these other treatment options please discuss this with the team.

You will be seen in the clinic to discuss any questions you may have about the procedure some time before the procedure.

On the day of the procedure your doctor will go through a written consent form with you to confirm that you are happy to proceed. You can withdraw your consent at any time should you wish.

If you are taking any medications at the time of the pre- assessment appointment, please bring them with you. You may need to stop some of your tablets before your procedure and will be given advice on this.

Please remember to let us know if you are taking any blood thinning medications like aspirin, clopidogrel, warfarin or rivaroxaban. Please remember that you should also bring your medications with you when you come for the procedure.

We will send you a letter confirming the date of your admission and details of where you should come to on the day of the procedure.

• Do not bring any valuables into hospital, as we cannot be held responsible for any loss or damage.
• Please remove all jewellery (except wedding rings).
• Please bring in some night clothes, day clothes and wash items. 
• Please have a contact number for the person who is going to take you home. 

You should have a responsible adult at home with you for the first 24 hours after you are sent home. If you live alone you should make arrangements for someone to stay with you.

You will be taken from the procedure room to the recovery area where you will be closely monitored. You will be connected to machines that monitor the activity of your heart. You will usually stay in recovery for an hour or two and then be transferred back to the ward. The exact time will be different for everybody.

You may be given oxygen until you are fully awake. This is given through a plastic tube which sits in your nostrils.

You may have a drip going into the back of your hand which will be giving you fluid. This is removed once you are drinking enough fluid.

You will be encouraged to get out of bed and move around on the day of the procedure.

We will aim to keep you on the ward for one night after the procedure. Sometimes we may be able to let you go home on the same day as the procedure but we will discuss this with you.

Some pain after your operation is normal. You will be given pain relief whilst you are asleep, and you should wake up feeling reasonably comfortable. If you have pain, please inform the nurse looking after you.

You can be given pain relief at regular intervals throughout the day. Do not wait until your pain is unbearable before you ask for medication. You will be given painkillers to take home with you. Make sure you take these when you need them.

Most people stay in hospital for one night following the ESD. You should have someone to take you home after the procedure. Please let us know if this will be difficult for you. If you have a long journey home and are travelling by car, stop every hour or so and stretch your legs to prevent yourself becoming too uncomfortable.

Once you are at home you can go back to your normal activities. If you experience any of the following symptoms please contact us (see page 11) as soon as possible:

• A temperature or fever
• Severe abdominal pain
• A swollen or distended abdomen
• Severe or uncontrolled vomiting
• Blood when you go to the toilet (more than an eggcup full)

It is best not to compare your recovery with other people who have had the same procedure. We are all different and recover at different rates.

You will be followed-up by the medical team in clinic to go through the results of the sample which was sent to the laboratory after your procedure. Once we have the results we will be able to decide whether you will need another colonoscopy to check the area where the lesion was.

Pathway Co-ordinator (Monday to Friday 09:00-17:00)
Direct line: 020 3447 9126 
Switchboard: 0845 155 5000 / 020 3456 7890 ext. 79126
E-mail: uclh.gimedicineenquiries@nhs.net 

Endoscopy Booking Team (Monday to Friday 09:00-17:00)
Direct line: 020 3456 7022 
Switchboard: 0845 155 5000 / 020 3456 7890 ext. 67022
E-mail: uclh.endoscopy@nhs.net 

Endoscopy Recovery (Monday to Friday 09:00-17:00)
Direct line: 020 3447 3282 
Switchboard: 0845 155 5000 / 020 3456 7890 ext. 73282

On-call Endoscopy Registrar (out of hour’s emergencies only) 
Switchboard: 0845 155 5000 / 020 3456 7890

Address: Endoscopy Unit, University College Hospital, 2nd Floor Podium, 235 Euston Road, London, NW1 2BU