1. Do you think gastrointestinal problems are increasing in the present scenario?

 In our present scenario gastrointestinal disease are like acidity, infections and tumors are increasing day by day because of our lifestyle such as  having contaminated-adulterated foods, junk foods and reduced consumption of foods rich in fiber-antioxidants (fruits). Lack of exercise and other habits such as drinking, smoking, and chewing tobacco are also contributing to these issues.

2. When should we suspect gastro-intestinal tumours?

We can suspect presence of these problems by specific (red signs) symptoms such as blood in the stools-vomitings, repeated severe abdominal pain with nausea and vomiting, black stool, severe constipation, weight loss, loss of appetite, jaundice, etc. They can also be detected during screening tests like screening colonoscopy for people over 50 years of age.

3. Are there any new methods to diagnose these gastrointestinal tumors in early stage?

Yes, there are new methods to diagnose these gastrointestinal tumors in early stage. They are called optical endoscopy: narrow band imaging, FICE (Fuji Intelligent Color Enhancement) and iScan technology. It utilizes the technology of cutting down red light but using other colours to lighten the image there by making the cancerous lesions more prominent and easily detectable. Through this, we can find out early cancer tumors from the gastro-intestinal tract. 

4. What is the conventional treatment for these gastrointestinal cancers?

Conventional treatment for these cancers is surgery. If the disease is localized, hasn’t spread much, surgical removal with or without chemo-radiotherapy will be curative. If these tumors can be identified at an early stage, then we can treat or remove them using third-space endoscopy methods.

5. What is 3rd space endoscopy?

It is also commonly referred as submucosal endoscopy, founded on the principle that the deeper layers of the gastrointestinal tract can be accessed by tunneling in the submucosal space without compromising the integrity of the overlying mucosa. First and second spaces are generally the spaces inside the intestine (lumen) and outside the intestine (space used in laproscopic surgeries). So technically third space is the space inside the wall of intestine between those two spaces. 

6. What are all the procedures that can be performed on the third space endoscopy?

We have many procedures mostly for cancers and some for non-cancerous diseases of the gastrointestinal tract. We call them: 1. EMR (endoscopic mucosal resection), 2. ESD (endoscopic submucosal dissection), 3. STER (sub-mucosal tunneling endoscopic resection) for cancerous and pre-cancerous lesions. Other procedures are 1. POEM (Peroral Endoscopic Myotomy) and ARMA-ARMS (Antireflux Mucosal Ablation, Mucosectomy) for non-cancerous problems. 

7. What are the advantages of these third space endoscopy procedures in patients with early gastrointestinal tumors?

In the standard treatment, open or laparoscopic surgery, the intestine or corresponding part is completely removed and joined back. In third space endoscopic procedures, we separate the layers of intestine using special techniques, carefully dissect the tumour from its base and remove it completely without compromising the integrity of the intestinal wall. Since it’s an endoscopic procedure, not much of discomfort would be noted to the patient, mobilization and feeding including discharge from the hospital can be done on same day or maximum next day. Very little blood loss is expected with these procedures also. 

8. Are there any other gastrointestinal diseases where third space endoscopy is useful?

These third space endoscopic procedures have been used in many other disease of gastro-intestinal tract also. One problem of difficulty in swallowing food known as achalasia cardia can be treated with POEM (peroral endoscopic myotomy). Other common problem of acidity like reflux – retrosternal burning which is treated with acidity pills (proton pump inhibitors) can be treated with ARMA-ARMS (anti-reflux mucosal ablation-mucosectomy).

9. What is achalasia cardia and its newer treatment POEM?

Achalasia cardia is the disease of food pipe (esophagus) with difficulty in swallowing food. Here the nervous connections in food pipe get degenerated (destroyed) and food pipe stops moving and food doesn’t move along the food pipe and gets stuck at the junction of food pipe and stomach. Traditional treatment of this was dilatation of this junction using endoscopic balloon or cutting the muscle surgically (Heller’s myotomy). With this newer third space endoscopy, we are able to cut this muscle using this newer technique called POEM – Peroral Endoscopic Myotomy. Here we enter the space between 1st and 3rd layers of food pipe wall, reach near the muscle, cut it with precision and under vision and close the opening created with clips. This procedure done under anesthesia takes 60-90 minutes and patient can be discharged on next day with resumption of feeding in 24 hrs. The results of POEM are as good as surgery or in some cases better than surgery making it the first choice of treatment in this condition.

10. Reflux problems, can they be addressed with this third space endoscopy?

Acidity coming back from stomach into the food pipe (esophagus) is called reflux. It happens due to bad food habits  and loose food pipe-stomach junction. Its commonly treated with acidity pills (proton pump inhibitors) taken in morning before food. Patients not improving with treatment, dependent on these pills, or develop complications due to reflux like ulcers, strictures – narrowing of food pipe, Barret’s esophagus – early precancerous lesion in food pipe, will need additional treatment. Traditional treatment was tightening this junction using surgery (Fundoplication). In few patients with favorable conditions, we can use this third space endoscopic techniques ARMA-ARMS (anti-reflux mucosal ablation-mucosectomy) to tighten the junction. 

11. Are there any side effects of these third space procedures?

Any treatment would have side effects. Similarly third space endoscopy procedures also have few side effects or complications like bleeding, perforation – formation of hole in intestinal wall and infections. These can be managed using endoscopic techniques like coagulation forceps, clip closure, etc. In severe complications, surgical and interventional radiology back up is necessary to treat these complications. However the incidence of these complications are less common, comparable to surgical treatment and can be reduced by using advanced endoscopic equipment and good expertise.