Flexible Endoscopy:The Surgical Perspective

Jonathan Pearl, MD

History of Surgical Endoscopy

Kelly, 1895 Hirschowitz, 1957

McCune, 1968 Shinya, 1968

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

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.

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

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.

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

Navy Data

• 566 colonoscopies by colorectal and general surgeons

• 97% cecal intubation• 27% adenoma detection• No perforation• No post-polypectomy bleed

Training Requirements

• RRC Requirements increased in 2009– 50 colonoscopies– 35 EGDs

• University of Maryland residents– 50-55 colonoscopies– 50 EGDs, including PEG

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

Competency

• ASGE: minimum thresholds before competency can be assessed– 140 colonoscopies– 130 EGD– 200 ERCP

• SAGES: Fulfill RRC requirements– Privileges granted by local authorities

Are numbers important?

• Want proficiency, not familiarity• Pushback from GI• Difficulty obtaining privileges

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.

Postgraduate Fellowship

• 3 programs with focus on endoscopy– Louisville– Miami– Case Western

• 100-200 colonoscopy• 200-300 EGD• 150-200 ERCP

How about simulation?

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.

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

Physical Models

Validation of Physical Simulator

• 21 experienced and 18 novices• Showed construct validity

Plooy AM, et el. GIE. 2012;76(1):144-50.

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

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

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.

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

Intraoperative Endoscopy

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

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.

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.

Managing Post op Complications

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.

Clips

Endoscopic Suturing

Endoscopic Suturing

Dilating Strictures

Reducing Stoma Diameter

Thompson CC, et al. Surg Endosc. 2006; 20(11):1744-8.

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

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%

Avoiding PEG Complications

• Does endoscopic experience matter?• Does it matter who performs PEG?• Are there techniques to reduce complications?

Endoscopic Innovations in Surgery

• NOTES• TIF• BARRX• Bariatrics• Resections• Closure of Perforations• POEM

TIF

TIF

Before After

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.

BARRX

RFA

• 90% eradication of low-grade dysplasia• 80% eradication of high-grade dysplasia• Ablation group– 3% disease progression– No invasive esophageal cancer

Endoscopy in Bariatrics

Gastrojejunal Barrier

Full thickness resection

Over the scope clips for GI perforation

POEM

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.

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