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38 Child andAdolescent Aspects inProphylactic Surgery
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465
possible short gut syndrome, and death. The sud­den onset of the symptoms after volvulus is typi­cal at this age with bilious vomiting, abdominal distension, abdominal tenderness, peritonitis indicating perforation, and rectal bleeding indi­cating bowel ischemia at later phase. In later childhood, the symptoms become more atypical like cyclic vomiting (often non-bilious), recur­rent abdominal pain, and failure to thrive [34]. Therefore, the syndrome of cyclic vomiting, psy­chosomatic illnesses, and parental neglect must be considered from a differential diagnostic per­spective [35].
38.9.2 Bariatric Surgery
Children with obesity often have a lowered self­esteem and an increased risk of being bullied [36], depressed quality of life, type 2 diabetes, obstructive sleep apnea, nonalcoholic steatohep­atitis, hypertension, dyslipidemia, and carbohy­drate intolerance. Binge eating disorder is the most common nutrition and eating disorder in pediatric obesity. It is an indication of psychopa­thology and a serious risk factor, especially in family obesity, negative experiences, and other factors predisposing to psychiatric disorders. Child and adolescent psychiatric counseling should be undertaken to identify cases at risk of psychotic disorders, major depression, personal­ity or eating disorders, alcoholism, and drug dependence [37]. Children are given antipsychot­ics not only for psychoses, but also for aggressive behavior or Tourette’s syndrome. They appear to be particularly vulnerable to antipsychotic­induced weight gain, regardless of taking olan­zapine or aripiprazole. This is often due to increased appetite in the family and/or during puberty without sufcient physical activity. The effects of nutritional advice, exercise programs, cognitive, behavioral, and pharmacological inter­ventions are moderate at best, but often insuf­cient, due to insufcient compliance [38]. According to the guidelines of the American Society for Metabolic and Bariatric Surgery [39],
metabolic and bariatric surgery is safe and effec­tive in adolescents.
In the postoperative follow-up anthropomet­ric, clinical and nutritional, including child and adolescent psychiatric assessment and counsel­ing, must be performed; early and late complica­tions have to be monitored [36]. Attention is needed to postoperative management of psycho­pharmacological treatment of patients undergo­ing bariatric surgery. Anatomical changes caused by bariatric surgery inuence the pharmacokinet­ics and the effectiveness of drugs, which can lead to ineffectiveness, side effects, and poisoning. Pre and postoperatively, the blood levels of the drugs must be monitored and the dosage adjusted if necessary [40]. There is strong evidence to sup­port a considerable alteration of the gut microbi­ome after bariatric surgery [41]. The microbiome appears to inuence many psychological pro­cesses and neuropsychiatric disorders, including mood and anxiety disorders, ADHD, and autism spectrum disorders. It is also likely that most psy­chotropic drugs have an inuence on the microbi­ome [42].
38.10 Conclusion
Illnesses and medical procedures like surgery cause a lot of emotional stress in children and adolescents and their parents. With prophylactic surgery, other difculties can show up like genetic testing and psychosocial dynamics in the decision- making process. Regardless of the dis­ease and the operation to be performed, children and adolescents considering their development levels should be sufciently informed and pre­pared about their illness, surgery, and periopera­tive procedures. Interaction between parents and children/adolescents is an important element by coping with disease and surgical processes. Psychiatric comorbidities in children/adolescents and their parents may have a signicant impact on the decision-making, (lifelong) coping with illness, and postsurgical and psychosocial adaptation.
466
A. S. Dilek Kasap and I. SpitczokvonBrisinski
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archpedi.1996.02170360021003.
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24. Barber JC, Ellis KH, Bowles LV, Delhanty JD, Ede RF, Male BM, Eccles DM. Adenomatous polyposis coli and a cytogenetic deletion of chromosome 5 resulting from a maternal intrachromosomal inser­tion. J Med Genet. 1994;31(4):312‐316. https://doi.
org/10.1136/jmg.31.4.312.
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Endoscopic Approaches forProphylactic Purposes
39
ÖmerKarahan andBarışSevinç
39.1 Introduction
In recent years, depending on the improvement in endoscopic methods, endoscopic approaches have come to the fore in the diagnosis and treat­ment of many gastrointestinal pathologies. Advanced procedures like endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) allow prophylaxis and treat­ment of early cancers. In this chapter, endoscopic procedures used in prophylaxis are discussed in view of literature.
39.2 Endoscopic Ultrasonography (EUS)
Endoscopic ultrasonography (EUS) is used for interventions rather than diagnostic approach. Examples of EUS-guided procedures are blockage and neurolysis of celiac nerve plexus, drainage of pancreatic pseudocyst, drainage of intra-abdominal abscess, drainage of bile and pancreatic ducts, choledocoduodenostomy, hepaticogastrostomy and intratumoral injec­tions [1–3].
EUS use is now considered as the gold stan-
dard for many gastrointestinal diseases,
Ö. Karahan (*) · B. Sevinç Department of Surgery, School of Medicine, Uşak University, Uşak, Turkey e-mail: omer.karahan@usak.edu.tr;
baris.sevinc@usak.edu.tr
especially for pancreaticobiliary diseases. EUS-guided needle insertion allows access to remote lesions that were difcult to reach in the past [3].
EUS is associated with an overall decreased mortality rate, fewer major and long-term com­plications compared to surgery, especially in patients with pancreatic pseudocysts [4] (Fig. 39.1). EUS-guided biliary drainage is an alternative to radiological interventions and ERCP [4]. Biliary drainage can be performed as EUS-guided hepaticogastrostomy or choledo­choduodenostomy [3, 4]. Moreover, drainage of intra-abdominal abscess or uids through trans­esophageal, transgastric or transcolonic route is possible [5]. These advantages of EUS provide the possibility of avoidance from high-risk surgi­cal procedures.
39.3 Endoscopic Polypectomy
Gastrointestinal system polyps are excised for both diagnosis and treatment. Removal of colonic polyps is an effective method in prevention of colorectal carcinoma. The features of the polyp, classication, ways for removal and histopatho­logical evaluation are all discussed in guidelines. For determination of surface morphology, Paris classication can be used. Localization of the lesion, diameters and morphology are situated in endoscopy report. Lesions larger than 10 mm should be pictured [6].
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 O. N. Dilek et al. (eds.), Prophylactic Surgery, https://doi.org/10.1007/978-3-030-66853-2_39
469
470
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Ö. Karahan and B. Sevinç
c
a
a
b
b
c
d
d
Fig. 39.1 Endoscopic drainage of pseudocyst; CT image of the pancreatic pseudocyst (a), radiological appearance of the stent placed in the pseudocyst (b), pseudocyst con-
tents discharge into the duodenum (c) and CT image, 2months after the procedure (d)
a b c
Fig. 39.2 ESD in early gastric cancer; FICE image of early gastric cancer (a), the lesion freed from its surroundings and from the oor (b) and tissue defect remaining after ESD is complete (c)
Excision of colorectal polyps by polypectomy decreases colorectal cancer incidence [7]. Moreover, polypectomy decreases the colorectal cancer-related death rate. Adenomatous polyps should be detected and removed endoscopically [8]. In pedunculated polyps, single polypectomy is sufcient. In sessile and large polyps, piece­meal polypectomy should be performed.
by AGA for endoscopic eradication of dysplasia developed in Barrett’s epithelium [11].
Endoscopic submucosal dissection (ESD) is an improved version of EMR.ESD mainly has three steps; rst one is the elevation of mucosa by submucosal injection. Submucosal injection pre­vents damage to deeper structures and reduces the risk of perforation and hemorrhage. The sec­ond step is the cutting of healthy mucosa around the lesion. The last step is the resection of the
39.4 Endoscopic Mucosal Resection
lesion by dissection of connective tissue below the lesion (Fig.39.2) [12].
As in EMR, before resection by ESD, the Early gastric cancer that will be treated by EMR should be well- or moderately differentiated ade­nocarcinoma, macroscopically elevated or depressed supercial lesions and have no inva­sion or ulceration [9]. EMR is used in premalig­nant or early gastric cancer as well as in treatment of esophageal, duodenal and colonic lesions. In well-evaluated cases, EMR is a good alternative to surgical resection [10]. Endoscopic surveil­lance programs have been started to be applied
lesion should be carefully evaluated by endos­copy, EUS and histopathology for localization, invasion depth, ulceration and metastases. In early gastric cancer, results of ESD are compati­ble with the results of radical gastrectomy. The postprocedural comfort of the patient is better, and hospital stay is shorter in ESD [13].
Although, it is more challenging compared to
stomach, benign, premalignant, malignant muco­sal and submucosal lesions of esophagus, small
39 Endoscopic Approaches forProphylactic Purposes
471
intestine and colon can be resected by ESD [14]. In selected patients, ESD has compatible onco­logic outcomes compared to surgery with low mortality and morbidity rate [14, 15]. In some ESD series, most of the cases are composed of benign and premalignant lesions. This fact indi­cates that ESD is an important treatment modal­ity as well as an important method for endoscopic prophylaxis [14].
In treatment of colonic lesions by ESD, en bloc resection rate is 82.8%, and perforation rate is 4.7%. Most of the perforations are so small that can be treated conservatively or by endoscopic clips application. The need for surgical interven­tion for perforation is very rare. In the near future, ESD will be widely used for early-stage colorec­tal cancers [16].
39.5 Radiofrequency Ablation
(RFA)
Since Barrett’s esophagus (BE) causes increased malignancy risk, for prevention of cancer forma­tion, BE should be treated [17, 18]. One of the treatment options in BE is RFA.By RFA, neo­plastic transition is prevented in cases with low­grade dysplasia [19]. Moreover, high-grade dysplasia can be safely treated by RFA [20]. In patients with dysplastic BE, both dysplasia and intestinal metaplasia can be completely eradi­cated by RFA, and the risk of progression is decreased [17]. Therefore, the risk of esophageal cancer development is reduced [19].
The combined endoscopic removal and RFA of the dysplasia safely and effectively treats the early esophageal neoplasia developed from BE [20].
Moreover, RFA of the lower esophageal sphincter signicantly reduces the complaints of reux. This feature of RFA can be an alterna­tive to medical treatment and surgical fundopli­cation [18].
Another application area of endoscopic RFA is the palliation of malignant biliary strictures. In palliation of malignant biliary strictures, RFA is a reliable and safe method [21].
39.6 Endoscopic Treatment ofGastrointestinal Bleeding
The timing of endoscopy in GIS bleeding depends on the clinical condition. Emergent endoscopy (within 24h) can be performed in the following: hematemesis in patient with a history of malignancy or cirrhosis, hypotension, tachy­cardia, shock, hemoglobin level below 8g/dL [22]. Variceal and non-variceal bleeding (peptic ulcer, gastroduodenal erosions, Mallory-Weiss lesions, etc.), active bleeding and stopped bleed­ing should be evaluated separately. There are several applications like topical, injection, mechanical and thermal methods. There is no standard treatment method that can be applied to all cases [23]. In bleeding ulcers, endoscopic treatment is used for cases with active bleeding or cases with high risk of rebleeding. In cases that bleeding is controlled, there is no need for repeat endoscopy; whereas, in cases with rebleeding, repeat endoscopy is needed. In low­risk patients, endoscopy can be performed as outpatient manner [22]. In some cases, more than one method can be combined, or medical treatment can be added to increase the success rate of the treatment [24].
Endoscopic ligation of varices reduces the risk of bleeding and mortality [25]. Band liga­tion of esophageal varices reduces mortality, upper gastrointestinal bleeding, variceal bleed­ing and serious adverse events compared to no intervention. Prophylactic endoscopic treatment can be applied to patients who cannot tolerate beta-blocker treatment with large and medium varices [25, 26].
In high-risk patients with non-variceal upper GIS bleeding-combined endoscopic treatment with proton-pump inhibitors reduces both mor­tality and rebleeding risk [27].
In lower GIS bleeding caused by angiodyspla­sia, diverticulosis and polypectomy, the success rate of endoscopic treatment is about 92% [28]. Endoscopic treatment methods that can be used are diluted epinephrine injection, bipolar electro­coagulation, heater probe, clips application and band ligation [29, 30].
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Ö. Karahan and B. Sevinç
39.7 Endoscopic Treatment ofGastrointestinal Stenosis
Endoscopic balloon dilation of upper gastrointes­tinal stenosis is safe and effective [31, 32]. Endoscopic dilation combined with endoscopic incision increases the success rate in gastric out­let obstruction [33]. After esophagus resection that continuity is provided by stomach, there is no need for pyloric drainage procedures. Early and late outlet obstruction can be treated by endoscopic balloon dilation [34].
In untreatable malignant gastric outlet obstruc­tion, duodenal stenting increases the quality of life [35]. In selected cases with benign obstruc­tion, duodenal stenting can be used [36]. In benign small intestine and colonic stenosis, bio­degradable stents can be applied easily [37].
As in other obstructions of the GIS, endo­scopic treatment can be used in stenosis due to Crohn’s disease [38]. In Crohn’s disease, endo­scopic balloon dilation of stenosis provides avoidance from surgery [39].
In colonic obstruction, stenting can provide elective surgery rather than emergency sur­gery. Moreover, in high-risk patients, it pro­vides time for preparation to surgery. In emergency surgery, most of the procedures necessitate ostomy and two-step surgery. Stenting of the obstruction can provide one­step elective and even laparoscopic surgery. The success rate of self-expandable stents can be as high as 97.8% [40].
In treatment of benign biliary stenosis, single or multiple temporary stenting can be used [41]. In biliary stenosis after liver transplantation, endoscopic balloon dilation, followed by stenting with gradually increased diameters, is the treat­ment of choice [42].
39.8 ERCP
Nowadays, ERCP is used for therapeutic pur­poses rather than diagnosis. ERCP has a wide­usage area; treatment of bile duct stones, stenting
of benign and malignant bile duct stenosis, treat­ment of Oddi sphincter dysfunction, palliation of neoplasia obstructing ampulla of Vater, treatment of bile stula, sump syndrome and parasitic dis­eases of bile ducts.
Bile duct stones, smaller than 1 cm, can be treated endoscopically with a success rate of 85%. Most of the larger stones can also be extracted by using special devices and techniques
43]. Stones larger than 2cm can be broken into
[ pieces and extracted by balloon and basket cath­eter. Endoscopic treatment rate of large stones after mechanical lithotripsy is 79–98% [
44, 45].
The complication rate of balloon extraction is lower than extraction with basket [46].
Adenoma of papilla Vater can be treated surgi­cally by local excision. Mortality and morbidity rate of this procedure is lower than the Whipple procedure; however, higher than the endoscopic treatment. Therefore, endoscopic treatment of ampullary adenoma has better results. Ampullary adenomas up to 2 cm can be treated by endo­scopic ampullectomy or endoscopic papillec­tomy. Surgical treatment should be chosen for adenomas with dysplasia or high risk for carci­noma. After endoscopic resection, adenomas can be followed endoscopically; however, if carci­noma exists, surgical excision should be per­formed [47].
In primary of metastatic tumors causing obstructive jaundice biliary drainage is needed. Biliary drainage even for palliation or prepara­tion to surgery treats cholangitis; itching, nausea and anorexia improves; quality of life increases. It can provide palliation in cases with terminal­stage malignancy. In preparation to surgery, drainage should be performed when the time to surgery is more than 15days; if there is cholangitis or bilirubin level is higher than 15mg/dL.Biliary drainage can be provided by ERCP, endoscopic sphincterotomy and stenting or by percutaneous transhepatic cholangiography. EUS-guided bili­ary drainage is a good alternative to percutaneous procedures [48–50].
In cases with malignant bile duct obstruction rate of curative treatment is only 10–15%. The
39 Endoscopic Approaches forProphylactic Purposes
473
rate of palliative treatment is very high. Self­expandable metallic stents (SEMSs) are used for palliation. Compared to plastic stents, SEMSs provide longer luminal patency period [51].
Rupture to biliary tree is an important compli­cation of hydatid cyst. It can cause obstructive jaundice and cholangitis. Rupture missed preop­eratively can cause postoperative complications like biliary stula, biloma, infection of the cyst cavity and obstructive jaundice [52]. ERCP is indicated in postoperative biliary stula and in cases with hydatid cyst membranes located in biliary tree. Biliary obstruction and cholangitis due to Fasciola hepatica and Ascaris are rare. The biliary obstruction caused by those parasites is also treated by ERCP [53–57].
ERCP is indicated in several pancreatic dis­orders like acute and chronic pancreatitis, pan­creatic pseudocyst, pancreatic duct stones and obstruction. Endoscopic treatment aims to reduce pressure of papilla Vater in acute pancre­atitis and to resolve pain in chronic pancreatitis (Fig.39.3) [58–60]. Main duct obstruction, pan­creatic cancer and pseudocyst may cause pan­creatic pain. The aim of the treatment is to decrease the pressure in the pancreatic duct to resolve pain.
ERCP is a modality that gains wider usage area for both prophylaxis and treatment of some disorders, without advanced surgical procedures.
Fig. 39.3 Papilla cannulation and sphincterotomy with ERCP
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