Medizinische Klinik C, Klinikum Ludwigshafen gGmbHGastroenterologie, Hepatologie, Diabetologie,
Gastroenterologische Onkologie
„KEY NOTE LECTURE“FUTURE OF ENDOSCOPY IN
GASTROENTEROLOGYJ.F. Riemann
L. Helmstädter
Falk-SymposiumFuture Perspectives in
Gastroenterology
Dresden, 11th-12th October 2007
Medical Department C, Klinikum Ludwigshafen, GermanyGastroenterology, Hepatology, Diabetes Care,
Gastrointestinal Oncology
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ENDOSCOPY
FUTURE PERSPECTIVES IN ENDOSCOPY
Quality Research
Technology
Prevention Interventions
Interdisciplinarity
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Diagnostics TherapyCombination1970
2007
HISTORY
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DIAGNOSTIC IMAGING
Structural Enhancement
High Definition Television (HDTV)
Chromoendoscopy (NBI, FICE, i-scan)
Adaptive IHb Color Enhancement
Autoflourescence-Imaging
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Structure EnhancementHDTV
(High Definition TV)
NBI(Narrow Band Imaging)
FICE(Fuji Intelligent Color
Enhancement)
DIAGNOSTIC IMAGING
Konventionell
NBI-Filter
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Adaptive IHb (Index of Hb)Color Enhancement
Colour Enhancement after calculation of hemoglobin concentration and comparison with
a reference index
Courtesy of R. Tamm, Olympus
DIAGNOSTIC IMAGING
AF CCD
Std CCDfor white light
endoscopy
LightGuide
LightGuide
biopsy
Autoflourescence-Imaging
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DIAGNOSTIC IMAGING
RED FLAG TECHNIQUESclear signal in the
presence of suspected lesions
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HISTORY OFSMALL BOWEL DIAGNOSTICS
push enteroscopyBenz et al., DMW 1997
In the 90s
use of transnasal sonde typeenteroscopesTada et al., Endoscopy 1986
intraoperative enteroscopyBosseckert et al., Endoscopy 1981
In the 80s
first use of endoscopes in small bowelClassen et al., DMW 1972
In the 70s
20th Century
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HISTORY OFSMALL BOWEL DIAGNOSTICS
21st Centurycapsule endoscopy (PillCam)Iddan et al., Nature 2000
2000
double balloon enteroscopyYamamoto et al., Gastrointest Endosc 2001May, Ell et al., Endoscopy 2003
2001
Olympus capsule (EndoCapsule)Hartmann et al., Endoscopy, accepted forpublication
2005
single balloon enteroscopyHartmann et al., Endoscopy, accepted forpublication
2007
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HISTORY OFSMALL BOWEL DIAGNOSTICS
notable simplification and improvement of proceduresexamination of the complete small bowelpossiblehigh diagnostic accuracytherapy in the hole small bowel possiblebecomes standard in all centers
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DIAGNOSTIC IMAGINGSmall Caliber Endoscopes
SpyGlass-SystemSingle-operator system
Four-way steering capability
Independent irrigationchannels
Diagnostic and therapeuticcapabilities
Disposable and multi-usecomponents
Courtesy of W. Weber, Boston Scientific
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FUTURE PERSPECTIVESPrevention
Incidence of CRC is increasingScreening-colonoscopy stagnates despitegood resultsShift in stages of CRCAcceptance is moderateImproved devices, new techniques
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Reasons for non-attendance of screening
no knowledge, no information 73%lack of interest, indecision 63%no time 62%fear of cancer 57%feeling healthy 43%no address / invitation 43%fear of examination procedure 39%mistrust in medicine 27%
V. Beck, Studie Stiftung Lebensblicke/DKG 2007
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Colono-Sight-SystemShike et al., DDW 2004
Cathcam-SystemGuidewire Colonoscopy
Fritscher-Ravens, Swain et al., Endoscopy 2006
FUTURE PERSPECTIVES„Smooth“ Colonoscopy Systems
Invendo-SystemHydraulic disposable
colonoscopeRösch et al., DDW 2007
Courtesy of A. Fritscher-Ravens
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Self propelling
Self navigating
Insufflation of CO2
360° Omni-View
FUTURE PERSPECTIVESAer-O-Scope
Vucelic, Arber et al., Gastroenterology 2006
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FUTURE PERSPECTIVES Aer-O-Scope
Scope-View X-ray (Pig)
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FUTURE PERSPECTIVESNeoGuide
Computer-assisted Colonoscope(partially automatic endoscope)
64 controllable segments and infraredsensors
Prevention of looping, pain, complications
Eickhoff A., Hartmann D, Van Dam J., Riemann JF; Am J Gastroenterol 2007
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FUTURE PERSPECTIVES NeoGuide
Simulation in an open model
conventional NeoGuide
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Ø11 mm
31 m
m
FUTURE PERSPECTIVESColon Capsule
Eliakim et al., Endoscopy 2006; Schoofs et al., Endoscopy 2006
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Pilot study capsule vs. colonoscopy at three centers:
Düsseldorf
Hamburg
Ludwigshafen (Management)
FUTURE PERSPECTIVESColon Capsule
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FUTURE PERSPECTIVESVirtual Colonoscopy
CT MRI
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FUTURE PERSPECTIVESVirtual Colonoscopy - CT
96.079.6Specificity93.888.7Sensitivity
≥10mm6-9mmAdenomatous Polyps
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LUVIK-Study
TANDEM CONCEPT
Pilot Study:
10084Sensitivity (Patients)10084Sensitivity (Polyps)
≥10mm6-9mm
Hartmann D et al., Radiology 2006
FUTURE PERSPECTIVESVirtual Colonoscopy - MRI
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FUTURE PERSPECTIVESInterventions
new Stents (e.g. oesophagus, biliary tract)
EMR ESD full-thickness resection1
endoscopic myotomy
interventional EUS
improved management of complications due to new suturing techniques
teleradiology (digital network-capable x-ray forbilio-pankreatic therapy) vs. open MRI
1Kaehler et al., Surg Endosc 2006
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FUTURE PERSPECTIVESStent Therapy
Oesophagus:SEMS loaded with 125Iodine-seeds in a rabbitt modelGuo et al., Eur J Radiol 2007
Enteral:partially covered double layer expandablenitinol stent in malignant gastoduodenalobstructionsKim et al., Gastrointest Endosc 2007
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Biliary tract:103Palladium radioactive stent in a dog modelHe et al., Hepatobiliary Pancreat Dis Int 2006
self-expandable helical biodegradable PLLA-stentMeng et al., J Mater Sci Mater Med 2006
SEMS with paclitaxel-eluting membrane (dog/human)Han et al., DDW 2007 / Lee et al., DDW 2007
FUTURE PERSPECTIVESStent Therapy
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FUTURE PERSPECTIVESESD
ERBE Hybrid-Knife
Courtesy of N. Yahagi
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Olympus R-Scope
Courtesy of R. Tamm, Olympus
FUTURE PERSPECTIVESESD
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FUTURE PERSPECTIVESEndoscopic Myotomy
submucosal endoscopic oesophageal myotomyPasricha et al.Endoscopy 2007
endoscopic pyloroplastyPark et al.Gastrointest Endosc 2007
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FUTURE PERSPECTIVESInterventional Endosonography
enteral anastomosesFritscher-Ravens et al.,
Gastrointest Endosc 2003
transgastriclymphadenectomy
Fritscher-Ravens et al.,Gastrointest Endosc 2006
transoesophageal intracardiacprocedures
Fritscher-Ravens et al., Endoscopy 2007
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g-Prox
double T-bar
Eagle-claw
FUTURE PERSPECTIVESEndoscopic Suturing Techniques
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FUTURE PERSPECTIVES Interdisciplinarity
Gastroenterologists & Surgeons
interdisciplinary Endoscopy
endopathology
NOTES
rendez-vous-techniquesnew dimension in
interdisciplinary tumor therapy
centers of competence
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Field of view: 500x500µmRange: 0-250µmLateral resolution: <1µm
Kiesslich et al., Gastroenterology 2003
FUTURE PERSPECTIVESEndomicroscopy
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predictive accuracy:
Barrett‘s epithelium 96,8%
Barrett‘s neoplasia 97,4%
Kiesslich, Gossner et al. Clin Gastroenterol Hepatol 2006
Helicobacter pylori
FUTURE PERSPECTIVESEndomicroscopy
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FUTURE PERSPECTIVESEndocytoscopy
Kumagai et al., Endoscopy 2004Squamous cell cancer
Normal squamousepithelium
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FUTURE PERSPECTIVES Interdisciplinarity
Endomicroscopy
Endocytoscopy
Molecular imaging
Endopathology
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FUTURE PERSPECTIVESN.O.T.E.S.
Natural Orifice Translumenal Endoscopic Surgery2004:
transgastric peritoneoscopy, appendectomy
2005:
transgastric tubal ligation, oophorectomy, hysterectomy, cholecystectomy, cholecystogastric anastomosis, gastrojejunostomy
2006:
transgastric distal pancreatectomy, splenectomy, lymphadenectomy
transcolonic cholecystectomy
2007:
transvaginal cholecystectomy, nephrectomy
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FUTURE PERSPECTIVESNOTES
Why NOTES-procedures:fast recovery (less pain, faster healing)
no hernia or infection of the abdominal wall
flexible access to intraabdominal areas, which are laparoscopically not or just difficult reachable (right flank of liver, underside of liver, retroperitoneum …)
no scares (attractive cosmetical result) ??
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FUTURE PERSPECTIVESNOTES
D-NOTES:e.g. Hochberger, Fuchs, Kähler, Meier, Feussner, Meining, Lamadé, Eickhoff
EURO-NOTES:e.g. Fockens, Bergström, Park, Fuchs, Lacy, Deviere, Swain
NOSCARe.g. Kalloo, Hawes, Rattner, Thomson, Swanström, Ponsky, Gostout
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FUTURE PERSPECTIVESNeoGuide NOTEScope
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FUTURE PERSPECTIVESNeoGuide NOTEScope
NeoGuide NOTEScope conventional endoscope
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FUTURE PERSPECTIVESNOTES
Multitasking PlatformDirect Drive System
C. Thompson, DDW 2007
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FUTURE PERSPECTIVESEndoscopic Research
molecular endoscopyprospective studiese.g. NBI-zoom-gastoscopy in patients with high risk for squamous cell cancer of the oesophagus
supply research (e.g. anti-reflux-studies)DFG Interest
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Endomicroscopy Immuno Histology
FUTURE PERSPECTIVESMolecular Endoscopy
Fluorescein labeledantibody (CD44)
Goetz et al., Endoscopy 2007
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FUTURE PERSPECTIVESQuality
standardized educationtraining centers (GATE, ENDOAkademie)improved simulatorsquality control (e.g. EPT-register)statistic of complications (transparency)
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ENDOSCOPY
FUTURE PERSPECTIVES IN ENDOSCOPY
Quality Research
Technology
Prevention Interventions
Interdisciplinarity
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ENDOSCOPY IN THE FUTURE
diagnostic precisionnew therapeutic dimensionsactive in researchinterdisciplinaryincreased quality-awareness
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to be continued ...
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