Flexible endoscopy a surgeon's perspective
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Flexible Endoscopy:The Surgical Perspective
Jonathan Pearl, MD
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History of Surgical Endoscopy
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Kelly, 1895 Hirschowitz, 1957
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McCune, 1968 Shinya, 1968
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History
• Kelly, 1895, sigmoidoscopy• McCune, 1968, ERCP• Shinya and Wolf, 1975, polypectomy• Sugawa, 1975, Endoscopic treatment of UGIB• Ponsky, 1975, colonoscopic tattooing• Ponsky and Gauderer, 1979, PEG• Stiegman, 1980, band ligation
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Endoscopy Volume
• 2434 surgeons sitting for recertification 1995-1997
• Average number of total procedures: 400• 51 (13%) endoscopic procedures– 21 Colonoscopy– 15 EGD– 3 PEG– Flex sig, bronch
Ritchie, WP et al. Ann Surg. 1999; 230(4): 533.
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Endoscopy Volume
• 10-year update– 4968 recertifying surgeons, 2007-2009• 533 annual procedures• Endoscopy procedures–Urban surgeons: 39–Rural surgeons (large population): 214–Rural surgeons (small population): 320
Valentine RJ, et al. Ann Surg. 2011; 254(3):520-6
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Surgeons do Endoscopy Well
• 13,580 surgeon-performed colonoscopies• Prospective database• 92% completion rate• 34% polyp detection rate• Low rates of complications– 10 bleeds, 10 perforation
• Experience matters– Higher completion rates with >100/yr
Wexner et at. Surg Endosc. 2001; 15(3); 251-261.
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Surgeons do Endoscopy Well
• 558 colonoscopy patients in VAMC• All colonoscopies performed by colorectal
surgeons• Surgeons met all standard quality measures– 99% performed for ASGE-approved indication– 97% cecal intubation rate– Adenoma detection rate 26%– 1 post-polypectomy bleed, 1 perforation
Tran Cao HS, et al. Surg Endosc. 2009. 23:2364-8
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Navy Data
• 566 colonoscopies by colorectal and general surgeons
• 97% cecal intubation• 27% adenoma detection• No perforation• No post-polypectomy bleed
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Training Requirements
• RRC Requirements increased in 2009– 50 colonoscopies– 35 EGDs
• University of Maryland residents– 50-55 colonoscopies– 50 EGDs, including PEG
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Position Paper
• ASGE, ACG, AGA• Concerns about ABS training numbers– “…inadequate especially when surgical residents
are required to perform only a fraction of the procedures requires to assess competency”
– Places undue burden on GI to achieve numbers
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Competency
• ASGE: minimum thresholds before competency can be assessed– 140 colonoscopies– 130 EGD– 200 ERCP
• SAGES: Fulfill RRC requirements– Privileges granted by local authorities
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Are numbers important?
• Want proficiency, not familiarity• Pushback from GI• Difficulty obtaining privileges
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Surgical Endoscopy Program
• Single center instituted a dedicated surgical endoscopy program for residents– 2 dedicated days– Residents at all levels– 4 year retrospective review
• Avg scopes 1999 graduates: 21• Avg scopes 2005 residents: 161
Morales MP, et al. Surg Endosc. 2008. 22(9)2013-7.
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Postgraduate Fellowship
• 3 programs with focus on endoscopy– Louisville– Miami– Case Western
• 100-200 colonoscopy• 200-300 EGD• 150-200 ERCP
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How about simulation?
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VR Simulation
• Early data discouraging– Construct validity of VR simulators– GI Fellow training• 10 hours of simulation training
– Useful for familiarization with equipment and technique
– No clinical difference after 15 colonoscopies
Cohen J, et al. GIE. 2006; 64:361-8.
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VR Simulation
• 36 trainees randomized to simulator training vs clinical training– 16 hours simulation training vs 16 hours patient-
based training– After training tested on simulator then 3 clinical
cases– Simulation group better on simulator– No difference in clinical colonoscopy
Haycock at al, GIE. 2010; 71(2)298-307
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Physical Models
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Validation of Physical Simulator
• 21 experienced and 18 novices• Showed construct validity
Plooy AM, et el. GIE. 2012;76(1):144-50.
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Fundamentals of Endoscopic Surgery
• Currently in development by SAGES• Didactic and skills-based• VR Simulator• 5 specific tasks– Navigation, Tool manipulation, Mucosal
Inspection, Retroflexion, Loop Reduction
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Back to Proficiency
• Goal of training in endoscopy – Proficiency, not familiarity
• Simulation may help in early training• Numerical milestones inadequate• Need a tool to accurately assess proficiency
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GAGES
• Global assessment of 60 novices and 79 experts• 2 expert observers• Results– Construct validity– Easy to use– External validity (multiple sites)
• May contribute to the definition of technical proficiency in basic endoscopy
Vassiliou et al. Surg Endosc. 2010; 24: 1834-41.
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Importance of Proficiency
• Comprehensive care of GI Surgery patients– Screening colonoscopy– Follow up for colon cancer– EGD for GERD– Localize colon cancer– EGD in bariatric patients
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Intraoperative Endoscopy
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Can endoscopy supplant UGI?
• 34 patients undergoing LPEHR• EGD after dissection and after wrap• No leaks, no wrap abnormalities• All underwent UGI– 1 column of barium
• EGD may supplant UGI in LPEHR
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EGD during LRYGB
• Retrospective review of 2311 patients• Intraop leak detected in 80 patients– Suture line reinforced in 46– 34 leaks only at high pressure
• Post op leaks detected in 4 patients– 2 had intraop leaks which had been reinforced
Haddad A, et al. Obes Surg. 2012.
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Pneumatic Testing during LRYGB
• 257 consecutive patients• Roux limb clamped; insufflation with
endoscope• Intraop air leaks in 25 patients– 13 persistent air leaks (repaired and drained)– 12 non-reproducible (drainage alone)– 2 post op leaks—not at G-J anastamosis
Kligman MD. Surg Endosc. 2007; 21:1403-5.
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Managing Post op Complications
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Stents
• Meta-analysis of 7 studies• 67 LRYGB patients with leaks• 88% closure with stents• 17% stent migration
Puli SR, et al. GIE. 2012; 75(2):287-93.
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Clips
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Endoscopic Suturing
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Endoscopic Suturing
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Dilating Strictures
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Reducing Stoma Diameter
Thompson CC, et al. Surg Endosc. 2006; 20(11):1744-8.
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Endoscopy after Fundoplication
• Tight fundoplication– Early—wait– Late—Balloon dilation
• Delayed gastric emptying– ?Injury to vagus nerves• Dilate pylorus, BOTOX injection
• Late dysphagia– Dilate fundoplication
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PEG Proficiency
• 160,000-200,000 PEGs performed annually in US
• Morbidity in 9%• Major complications in 1-3% of cases• Mortality in 0.5%
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Avoiding PEG Complications
• Does endoscopic experience matter?• Does it matter who performs PEG?• Are there techniques to reduce complications?
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Endoscopic Innovations in Surgery
• NOTES• TIF• BARRX• Bariatrics• Resections• Closure of Perforations• POEM
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Before After
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TIF Data
• 100 consecutive reflux patients in 10 centers• GERD-HRQL normalized in 73%• 80% off PPIs at 6 months• Significant reductions in reflux and
regurgitation scores• No pH data
Bell at al. J Am Coll Surg. Aug 2012.
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BARRX
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RFA
• 90% eradication of low-grade dysplasia• 80% eradication of high-grade dysplasia• Ablation group– 3% disease progression– No invasive esophageal cancer
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Endoscopy in Bariatrics
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Gastrojejunal Barrier
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Full thickness resection
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Over the scope clips for GI perforation
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POEM
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Long-Term Outcomes
• 18 cases over 1 year• 1 full-thickness perforation• All 18 with dysphagia relief• 2 patients with non-cardiac chest pain• 50% with reflux at 6 mos on pH probe– 6 patients complained of pyrosis
Swanstrom LL, et al. Ann Surg. Oct 2012.
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Summary
• Surgeons perform endoscopy well• Endoscopic training should focus on
proficiency• Proficient endoscopists provide
comprehensive care to GI surgical patients• Many surgical innovations have endoscopic
platform• Endoscopy will be integral in GI surgery
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