Third Space Endoscopy

Third Space Endoscopy is an advanced form of therapeutic endoscopy that uses specially created tunnels within the layers of the gastrointestinal tract to diagnose and treat selected digestive disorders. Unlike conventional endoscopy, which primarily works on the surface lining of the digestive tract, third-space techniques allow specialists to access the deeper layers of the gastrointestinal wall without the need for traditional open surgery.

These procedures are performed using highly specialized endoscopic equipment and techniques. They can be used for conditions involving the oesophagus, stomach, and other parts of the gastrointestinal tract, particularly disorders affecting the muscular layers or lesions located beneath the surface lining.

Our Third Space Endoscopy service provides advanced minimally invasive treatment for carefully selected patients, with an emphasis on accurate diagnosis, appropriate patient selection, and safe therapeutic intervention.

What Is Third Space Endoscopy?

The gastrointestinal tract is made up of several layers. Conventional endoscopy allows doctors to examine the inner surface of the digestive tract, while standard surgical procedures can access deeper structures through external incisions.

Third Space Endoscopy creates a controlled passage, or submucosal tunnel, within the wall of the gastrointestinal tract. This provides access to structures beneath the surface without requiring a conventional surgical incision.

Once the endoscope enters this artificially created space, specialized instruments can be used to perform procedures such as muscle division or removal of selected subepithelial lesions.

After the treatment is completed, the entry point into the tunnel is closed using endoscopic clips or another appropriate closure technique.

Conditions Treated With Third Space Endoscopy

Third-space techniques have expanded the range of conditions that can be treated using advanced endoscopy.

Depending on the patient’s diagnosis and anatomy, procedures may be considered for:

• Achalasia and other oesophageal motility disorders
• Selected oesophageal and gastric subepithelial lesions
• Certain gastrointestinal wall tumours
• Disorders caused by abnormal muscular contractions
• Selected conditions requiring access to the submucosal or muscular layers

The exact procedure is determined by the location and nature of the condition, symptoms, previous treatment, and overall health.

Peroral Endoscopic Myotomy (POEM)

One of the best-known third-space endoscopic procedures is Peroral Endoscopic Myotomy (POEM).

POEM is used primarily to treat achalasia, a disorder in which the lower oesophageal sphincter does not relax normally and the oesophagus has difficulty moving food into the stomach.

Patients with achalasia may experience difficulty swallowing, regurgitation, chest discomfort, or unintended weight loss.

During POEM, the endoscope is introduced through the mouth and a small entry point is created in the oesophageal lining. A submucosal tunnel is carefully developed toward the lower oesophageal sphincter.

The specialist then divides selected muscle fibres that are preventing normal relaxation. After the myotomy is completed, the entry point is closed endoscopically.

The goal is to reduce resistance at the lower oesophageal sphincter and improve the passage of food into the stomach.

Endoscopic Removal of Subepithelial Lesions

Third-space techniques can also be used to access selected subepithelial lesions. These are abnormalities that originate beneath the superficial lining of the gastrointestinal tract.

A lesion may appear as a smooth bulge during routine endoscopy even though the abnormal tissue is located deeper within the gastrointestinal wall.

Endoscopic techniques can sometimes allow the specialist to obtain tissue for diagnosis or remove selected lesions through the endoscope.

The suitability of endoscopic removal depends on factors such as lesion size, location, depth, appearance, relationship to surrounding structures, and suspected diagnosis.

In carefully selected patients, endoscopic resection may avoid the need for more invasive surgery.

Advantages of Third Space Endoscopy

Third-space procedures offer several potential advantages for appropriately selected patients.

These may include:

• Minimally invasive treatment
• No external surgical incision
• Access to deeper layers of the gastrointestinal wall
• Ability to treat selected muscular disorders
• Potentially shorter recovery compared with conventional surgery
• Ability to obtain tissue or remove selected lesions
• Endoscopic treatment of conditions that previously required surgery

However, these procedures are technically demanding and are not appropriate for every patient. A detailed evaluation is necessary before recommending treatment.

What to Expect During the Procedure

Third-space endoscopic procedures are generally performed in a specialized endoscopy unit under general anesthesia or deep sedation, depending on the procedure and patient’s condition.

Before treatment, your specialist will review your symptoms, medical history, previous procedures, medications, allergies, imaging, endoscopy reports, and other relevant investigations.

You will usually need to fast before the procedure. Specific instructions will be provided regarding medications and other preparation requirements.

During the procedure, the endoscope is introduced through the mouth. A small entry point is created in the gastrointestinal lining, allowing the specialist to enter the submucosal space.

A tunnel is carefully developed to reach the target area. The required treatment is then performed using specialized endoscopic instruments.

At the end of the procedure, the entry point is closed securely using endoscopic clips or another suitable technique.

Patients are monitored after the procedure and may require hospital observation depending on the type and complexity of treatment.

Recovery After Third Space Endoscopy

Recovery varies according to the procedure performed and the patient’s individual condition.

After certain procedures, patients may initially receive fluids through a vein and have their diet gradually advanced according to the specialist’s recommendations.

Follow-up may include clinical assessment, imaging, endoscopy, or other tests depending on the treatment performed.

For patients undergoing POEM, follow-up is important to assess improvement in swallowing and other symptoms and to monitor for complications such as reflux.

Patients undergoing endoscopic lesion removal may require pathology review and follow-up endoscopy or imaging to confirm complete treatment.

Risks and Possible Complications

Third-space endoscopy is an advanced procedure and carries potential risks.

Depending on the procedure, complications can include bleeding, infection, perforation or leakage, chest or abdominal discomfort, pneumoperitoneum, adverse reactions to anesthesia, and other procedure-specific complications.

After POEM, gastroesophageal reflux can occur because the treatment reduces the resistance of the lower oesophageal sphincter. Patients may require monitoring and, when appropriate, treatment for reflux.

The overall risk depends on the type of procedure, the underlying condition, the patient’s anatomy, and other individual factors.

Your specialist will explain the potential benefits, risks, alternatives, and expected recovery before treatment.

Who Is a Candidate for Third Space Endoscopy?

Not every patient with a digestive disorder requires third-space endoscopy. A detailed evaluation is necessary to determine whether the procedure is appropriate.

Assessment may include endoscopy, high-resolution manometry, contrast studies, CT or other imaging, EUS, and other investigations depending on the suspected condition.

The specialist considers the diagnosis, severity of symptoms, previous treatments, anatomical factors, and overall health before recommending an advanced endoscopic procedure.

Why Specialist Expertise Matters

Third Space Endoscopy requires advanced training in therapeutic endoscopy and a thorough understanding of gastrointestinal wall anatomy. Procedures such as POEM and endoscopic subepithelial lesion resection require careful technique and appropriate management of potential complications.

Our Third Space Endoscopy service offers advanced minimally invasive treatment for selected gastrointestinal conditions that involve the deeper layers of the digestive tract. The goal is to provide effective treatment while minimizing the need for conventional surgery when endoscopic therapy is appropriate.

If you have achalasia, a gastrointestinal motility disorder, a subepithelial lesion, or another condition that may benefit from advanced endoscopic treatment, a specialist consultation can help determine whether Third Space Endoscopy is suitable for you.