Saowanee Ngamruengphong is on a mission to reduce the number of surgeries performed on patients who could benefit from less invasive procedures. “So many times, there are alternatives to things like proctectomy,” says the Johns Hopkins gastroenterologist. “If the patient needs it, that’s one thing. But let’s see if there might be another approach.”
Ngamruengphong teams with colorectal surgeon Sandy Fang to take a minimally invasive approach to some of the most difficult-to-resect rectal cancers. Her endoscopic submucosal dissection [ESD] training, undergone at Tokyo’s National Cancer Center, allows her to use an endoscope to remove parts of lesions and tumors in the GI lumen, a millimeter at a time.
“So many patients in the United States with this large colorectal lesion undergo surgery, since that’s what is recommended to them,” says Ngamruengphong. “Even if it’s successful, some of them have the whole rectum removed and have to live with an ostomy bag for the rest of their lives.”
She notes a recent case of a woman with a large lesion on the anterior wall of the rectum. Ngamruengphong and Fang collaborated to remove the lesion while avoiding cutting through the wall and encroaching into the patient’s vagina.
“Many bad things can happen in surgeries like this,” says Ngamruengphong. “My job is to dissect the lesion a tiny bit at a time, never going outside the GI tract.”
After her part of the removal, Ngamruengphong made way for Fang, who completed the procedure using a minimally invasive transanal technique.
Ngamruengphong and Fang published the case in the Endoscopy journal this year, noting that this approach was a first in the United States. She adds that the patient went home the next day and has recovered fully.
“When we have difficult cases, we work with our colleagues to come up with what’s best for the patient,” she says. “At Johns Hopkins, our surgeons and our pathologists and oncologists—we all work together.”
In addition, Ngamruengphong is trained in a new endoscopic resection technique called endoscopic full thickness resection, or EFTR, where lesions in the colon are resected using a technique that gathers the lesion and the tissue around it bunched in a clip. She resects the tissue just above the clip, then snips off tissue containing the lesion.
“We can remove the whole thing, including margins,” she says. “There’s no hole to close up. It’s already closed before we remove the lesion.”
Ngamruengphong also has trained to spot gastric lesions early enough to avoid them becoming cancerous.
“Because stomach cancer is more common in Japan than in the U.S., they’re better at spotting it,” she says. “When I was a med student and a resident, I never saw early stomach cancer. But after I trained with the experts, I know what these lesions look like in their earliest stages.”
Ngamruengphong describes a patient whose biopsy showed gastric cancer without suspicious lesions in the stomach. Before coming to her, the patient had had several ablations on a whole biopsied part of the stomach.
“They just ablated the whole area and that definitely didn’t work,” she says, noting that the lesion returned repeatedly, each time larger than before. Then the patient was recommended to undergo gastrectomy. “She came here and we were able to resect the lesion endoscopically using the ESD technique. It was an early gastric cancer, and the patient’s doing well.”
Too often, she says, gastric lesions are missed and are only spotted when they become advanced cancer.
“But when you see it and you treat it, it can be lifesaving.”