New York—What do colonoscopy, polypectomy and endobiliary stenting all have in common? They are all endoscopic techniques first described by surgeons, along with control of hemorrhage, endoscopic retrograde cholangiopancreatography, percutaneous endoscopic gastrostomy/jejunostomy and control of variceal bleeding.
“It’s an old adage that general surgeons started endoscopy and gave it up to the gastroenterologists,” said Paresh C. Shah, MD, professor of surgery at NYU Langone School of Medicine, in New York City. “Unfortunately, that’s true, but we’re changing that and we need to be aggressive about it.”
The American Board of Surgery has acknowledged the importance of surgical endoscopy through changes in residency training requirements for board eligibility. Starting in 2018, surgical residents will have to complete a flexible endoscopy curriculum and pass the Fundamentals of Endoscopic Surgery (FES) examination assessing their cognitive and technical skills. The FES program was developed by the Society of American Gastrointestinal and Endoscopic Surgeons.
But surgical endoscopy can expand and enhance practice for surgeons at any stage in their career, Dr. Shah explained at the 2016 Controversies, Problems & Techniques in Surgery annual meeting, noting that it was general surgeons again who played a role in promoting some of the more advanced endoscopic interventions, such as EndoCinch suturing, Stretta, anastomotic plication and peroral endoscopic myotomy (POEM).
“If we think of ourselves as gastrointestinal surgeons, we’re really obligated to look at the spectrum of what GI surgery is. Advanced endoscopy, therapeutic endoscopy, is nothing more than another form of GI surgery; it’s just one that happens within the lumen rather than outside.”
In the world of diagnostic endoscopy, some of the newer tools that surgeons have include microendoscopy and narrow-band imaging. “For those of you who do diagnostic upper and lower endoscopy, these are critical to have at your disposal,” Dr. Shah said. “They’ve impacted adenoma detection rate, early cancer detection, and clearly, postsurgical anatomy.”
As Jose Martinez, MD, pointed out, nobody understands postsurgical anatomy better than the surgeon who made it. “We do a lot of replumbing in the human body, and we know the plumbing doesn’t always work. We can end up with strictures or worse—a leak, fistula or perforations,” said Dr. Martinez, associate professor of surgery and chief of laparoendoscopic surgery at the University of Miami Miller School of Medicine.
Basic tools for interventional endoscopy include balloon dilation, bleeding control and feeding tubes. More advanced interventions—to manage complications that surgeons themselves may have created—include stents, clips, fibrin glue and endoscopic suturing.
Injection is an important skill to develop. “It allows you to do a lot of things in the GI tract, whether you’re injecting saline to lift the mucosa, tattoo to mark a lesion or epinephrine to control bleeding,” Dr. Shah said.
The application of clips, which have improved dramatically in recent years, also has myriad uses. “Closing small holes, mucosal defects; I use clips after endoscopic submucosal dissection (ESD) resections and peroral endoscopic myotomy, and they’re good for bleeding control,” Dr. Shah said.
When it comes to dealing with strictures, surgeons again have a number of tools at their disposal: stents, energy sources, balloons and dilators. “Many of these things were created for one purpose, but we’re using them in different ways to figure out how to best accomplish treatment for our patient,” Dr. Martinez said.
And then there are the very advanced endoscopic interventions: POEM, gastric POEM (G-POEM), ESD and endoscopic full-thickness resection (EFTR). “G-POEM changed our practice—I don’t do pyloroplasties anymore; and ESD and EFTR are now the avant- garde of what we can do endoluminally,” Dr. Shah said.
Incorporating Endoluminal Techniques
Jeffrey Marks, MD, long a promoter of flexible endoscopy, acknowledged that while the younger generation of surgeons might be more comfortable with it—especially the residents who will have to pass the FES and complete the flexible endoscopy curriculum in 2018 before sitting for their boards—more established surgeons can be a tougher sell.
“The hardest person to impress is the person outside fellowship and residency, someone in practice already. If they’re not doing flexible endoscopy, it’s hard to get them started,” said Dr. Marks, professor of surgery and director of surgical endoscopy at Case Western/University Hospitals, Cleveland Medical Center, in Ohio.
Drs. Marks and Shah recommend surgeons start with intraoperative assessment. “For one thing, the GI doctors aren’t going to want to come in to assess every anastomosis or bariatric bypass; also, the patient being asleep makes it easier—you don’t have to worry about them being uncomfortable—so it’s a great way to gain skills.”
Dr. Shah suggests having an endoscope involved in every case. “There is no downside to you doing your own intraoperative endoscopy, whether it’s foregut or colon.”
Once a surgeon has gained some comfort, some formal training can advance his or her competence. “Both the American College of Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons have hands-on courses for surgeons who have a basic skill set in flexible endoscopy to learn how to do more advanced therapies,” Dr. Marks said.
Dr. Shah also recommends working with GI colleagues to build one’s skill set for more advanced endoscopic procedures. “Most of them have more experience than you with the more advanced procedures,” he said.
This can be difficult politically in situations where gastroenterologists sense a turf war and resist sharing what they know, but the reality, according to Dr. Shah, is that most gastroenterologists are more than willing to turn over the more challenging and relatively less remunerative advanced endoscopic procedures. “It does not pay for them to do a two-hour procedure when they can do six screening colonoscopies in the same time. The reimbursement isn’t there for them, the interest isn’t there for them, and they don’t want to be responsible for potential complications.
“If you have a therapeutic or developmental endoscopist in your area or practice, partner with them,” he said. They’ll love to have that work with you. And if you don’t have a therapeutic endoscopist, there’s a very good opportunity for you to become that person for your GI community. They’ll be happy to do your pre-ops, screenings and post-ops, and to call on you when they need one of these more advanced therapeutic endoscopic procedures.”