Extreme endoscopy: Innovators unite

Advances in endoscopy have, without a doubt, revolutionized gastroenterology. But to forward-thinking clinicians who view this as a time in the technology’s infancy, tremendous potential is still waiting to be tapped. Some anticipate a not too distant future when truly minimally invasive endoscopic procedures will reproduce the results now achieved with laparoscopy or conventional surgery. Such endoscopic intervention would potentially allow patients to leave the operating room suite with less pain than experienced with laparoscopy and no external signs that they had undergone a procedure. In essence, many of the surgical maneuvers in which organs are accessed from the outside in could, conceivably, be done from the inside out, including cleanly cutting and stitching tissue, rejoining the edges of tissue in a manner that approximates the natural condition, and even organ removal.

However, before such radical techniques gain even limited acceptance, demand for them much reach a critical mass and clinicians must be convinced that they are safe, effective and relatively simple. Predicted that such procedures will catch on more readily when they can be taught effectively and are able to be reversed. Few endoscopic surgical applications currently meet all of these criteria, but has little doubt that an open mind bolstered by serious technological advances will be the key to successful new endoscopic procedures.

Technological advances

Already pointed out, there are a number of devices on the market designed to surgically address gastroesophageal reflux disease (GERD). However, they don’t quite reach the level of efficacy and simplicity that would push them over the top to become replacements for existing surgical or medical treatments. The first generation instruments are "important not because they’ve created a solution, but because they broke the conceptual barrier and have shown that the goal is reachable within three to five years. Eventually, something reliable will come along that will become the primary device used for the endoscopic treatment of patients with GERD.

Other areas to keep an eye on are endoscopic approaches for obesity, organ resection and gastrojejunal anastomosis. Also raised the very real possibility of "way-out" applications, such as endoscopic implantation of electrical pacing devices to treat chronic GI pain, constipation and incontinence. There’s a huge amount of money being poured into technology for advanced endoscopic procedures. They are currently working on their own endoscopic anti-reflux procedure. Early clinical trials have provided encouraging results. The device employs an overtube that surrounds the endoscope and allows placation around the gastroesophageal junction.

We think that’s a critical region for preventing reflux, and one that prevents transmission of extending forces to the lower esophageal sphincter.

New applications

That much of the emerging technology is focused on "big ticket" conditions such as GERD and obesity, yet there’s a lot of "low-hanging fruit" and unmet needs that current procedures are not addressing and should not be neglected. For example, technological advances may result in a scenario where colonoscopy is conducted by a highly trained non-physician, thereby improving efficiency and ameliorating the sharp downward reimbursement trend for the procedure. However, physicians would continue to supervise, integrate and interpret results. Even envisioned the prospect of one endoscopic overseeing several colonoscopies simultaneously – GI nurses would advance the scope to the cecum and, with the help of computer-aided analysis of the video, begin to back the scope out. The endoscopist would finish the procedure and conduct any therapeutic interventions, such as polypectomy.

Many of his colleagues have voiced skepticism about pushing the extremes of endoscopic applications, particularly clinicians that are use to – and satisfied with – treating some GI disease states pharmacologically. That is going to shift. Part of the skepticism has probably arisen because some of the new devices have been overhyped and perhaps prematurely brought to market. That’s resulted in people saying ‘aha’ because the new technology didn’t meet expectations, but that’s true of anything that’s new.

Peroral procedures

Chief of the Division of gastroenterology at Johns Hopkins Hospital, Baltimore, is among the pioneers experimenting with endoscopic maneuvers that were virtually inconceivable only a couple of years ago – such as performing therapeutic interventions in the peritoneal cavity perorally instead of laparoscopically. We’ve accessed the peritoneal cavity in porcine models endoscopically via the mouth. This has gone against the grain because it would be considered a major complication if a perforation was made into the peritoneal cavity itself form the inside out. That serious safety issues have been addressed by measures such as I.V. antibiotic coverage, irrigation of the stomach with antibiotic solution and the use of a special overtube that prevents intestinal contents from leaking into the peritoneal cavity. To date, doctor has reported his experienced with peroral transgastric approaches to liver biopsy, gastrojejunostomy and fallopian tubal ligations. But why go through all that trouble, when laparoscopy produces solid results with low morbidity and allows more patient to return quickly to normal activities?

We think this offers additional advantages. It’s even less painful and less invasive than laparoscopy. There are no abdominal muscle incisions, and even laparoscopy can be painful. Some (laparoscopy) patients still need several days to return to routine activities. In addition, the peroral approach may be particularly useful in obese patients, for whom accessing the abdominal cavity surgically or laparoscopically can present significant intraoperative challenges. By avoiding the abdominal wall, we may reduce some of the difficulty getting into the peritoneal cavity inpatients with thick abdominal walls. And cosmetically, there are zero scars. He predicted that his peroral transgastric approach will be ready for clinical trials within a year or two.

Doctor also confronted skeptics, but he has noticed that their number and level of doubt have gradually declined as he and others demonstrate incremental, but unmistakable, progress toward an elusive goal. Many wonder why we should do this, since laparoscopy is already so good. They also ask, who’s going to do these procedures, surgeons or endoscopist, and if there are complications, who will be on hand to handle emergencies? All are valid questions that only time and experience can sort out. Also acknowledged the limits of the technology: They don’t think this approach will ever completely replace standard surgery, and we need to do extensive due diligence to ensure that it’s safe in humans, but these procedures will find a niche in surgical management.