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I chose to go with Underwater EMR, and had my procedure performed by Dr Kenneth Binmoeller

December 3, 2015

 

A few months ago, I was diagnosed with several large, problematic colon polyps during a routine colonoscopy, and was thereafter referred to a surgeon to have them removed.  I met with two surgeons, who both gave me the same bad news: that I needed either a partial colectomy.

I am writing this with the intention of giving some insight to those who
find themselves in a similar situation, in hopes that they may find my
story beneficial (in particular, the route of treatment that I chose to
pursue).

Procedures for non-surgical removal of colon polyps are not common
knowledge to most patients. These non-surgical techniques are relatively new, and are only performed by a small number of gastroenterologists who have undergone specific training.

While researching my options, I came across
www.sease.com<http://www.sease.com/>, a website created by a patient named Jim Sease.  I am incredibly thankful to him for creating this site, which is essentially a treatise on endoscopic mucosal resection (EMR), a type of non-surgical polyp removal.

Further reading yielded the following article on a novel technique ,
called "Underwater EMR"  developed by Dr Kenneth Binmoeller:

http://www.jigjournal.org/sites/default/files/113-116%20%20JIG-2014.pdf ,

The above publication, among others, clarified for me the differences
between two non-surgical techniques available to remove large,
problematic colon polyps: the standard EMR versus the underwater EMR
technique .

EMR, in a nutshell, involves a physician using a rectal endoscope
(basically a camera on a long wire through a narrow tube, with lights and
instruments), to find and remove abnormal tissue from the colon.

This holds true for both standard EMR and underwater EMR.

So now let's look at the differences between the two techniques.
Firstly, as its name would imply, underwater EMR is a procedure done
"under water", while standard EMR is not.  Let me explain:

During standard EMR, the intestines are inflated with gas, which creates
enough space for the surgeon to work inside, and allows them to search
the colon for other abnormal tissue.

During Underwater  EMR, on the other hand, gas is replaced by water. So instead of using gas to inflate the intestines, the surgeon uses saline
(which is just water with salts in it), to create space to work within
the colon.

Basically, that's the "big" difference.  But from this one change, there
are a surprising number of advantages that are gained by using the
underwater technique.

First of all, the underwater technique allows the surgeon to see more
clearly.  You can watch videos that demonstrate this here:
https://vimeo.com/69845248

But even more importantly, underwater EMR avoids the sub-mucosal
injection that most standard EMR procedures involve. The sub mucosal
injection basically involves injecting saline near the abnormal tissue,
in a very difficult place to inject: in between two very thin layers of
tissue.

Here are some of the problems associated with the submucosal injection
used in the standard EMR ,that are avoided with Underwater EMR :

1). There is the risk of injecting saline too deep during submucosal
injection.

Like our skin, the lining of our colon has multiple layers.  During the
submucosal injection, what the doctor is trying to do is separate the top
layer from the next one below it, so that it is easier to remove JUST the
top layer. However, this is very difficult to do without pushing the
needle too deep.

Imagine you have a pizza -- many layers, with cheese on top of bread.

Now using a needle, poke through the cheese so that you can squirt water IN BETWEEN the cheese and bread.  This will make the cheese rise up a little bit, and separate from the layer below it, making it easy to just
go in and remove the cheese.  HOWEVER, you could push the needle too far. Now you are injecting water into the bread, and both layers are puffed up.

What this is saying is that if during that submucosal injection, they
inject a bit too far (too deep), they will cause more than just the top
layer of tissue to lift. Then, the snare (the cutting tool) will capture
more tissue than just the abnormal outer layer.

This defeats the purpose, which was to make the outer-most layer easy to remove!

2) There is a risk of infection during submucosal injection.

Sometimes, due to a misdirected injection outside the bowel wall in
standard EMR,there is a risk of infection at the injection site, a risk
avoided using underwater EMR since there is no injection.

3) There is also the risk of "needle track seeding" at the injection site.

There is the theoretical potential (and there is some evidence that this
can happen) that the needle puncture itself can push abnormal cells
deeper into the tissue!

Think about it like this -- cells are SMALL.  Almost as small as the tip
of a needle.  So when you push a needle into tissue, it takes a lot of
cells with it (pushing them forward into deeper areas of tissue).  This
is the same concept as why you wash a kiwi before cutting it.  You don't
eat the skin, but just by cutting through the kiwi, you can push germs
from the skin into the meat, because they get pushed by the blade itself!

Same concept here -- if there are abnormal cells on an outer layer, and
you stick a needle through that layer, the needle can push some of those
cells deeper into the tissue, where they can linger and grow, causing
problems in the future.

The risk of needle track seeding is entirely avoided using the
Underwater EMR technique, since there is no submucosal injection involved!

After reading all this, I chose to go with Underwater EMR, and had my
procedure performed at CPMC in San Francisco by Dr Kenneth Binmoeller in December of 2015.

My procedure couldn¹t have possibly gone better.  My experience with the whole staff was comfortable and relaxed ‹ I felt that I was very well
taken care of.  As far as recovery, it was like nothing had ever
happened.  No pain, no discomfort, nothing!  I was simply amazed at how
smoothly my recovery went.  I had read in Jim Sease's blog (
www.sease.com<http://www.sease.com/>) about a short recovery period, with some discomfort and I was prepared to experience this. But from the moment I woke up from anesthesia, I felt as if no procedure was performed. I immediately resumed my normal activities !

As for Dr Binmoeller , words cannot describe this charismatic and gifted
doctor ! It is less than common to encounter a doctor who combines such superior skills , knowledge, experience and zeal for advancement with warmth , confidence and kindness . One that makes you feel right away reassured that you made the best choice !

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