A grand rounds presentation on flexible endoscopy for surgeons.

1. Flexible Endoscopy:
The Surgical Perspective
Jonathan Pearl, MD

2. History of Surgical Endoscopy

3. Kelly, 1895 Hirschowitz, 1957

4. McCune, 1968 Shinya, 1968

5. 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

6. 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.

7. 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

8. 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.

9. 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

10. Navy Data
• 566 colonoscopies by colorectal and general
surgeons
• 97% cecal intubation
• 27% adenoma detection
• No perforation
• No post-polypectomy bleed

11. Training Requirements
• RRC Requirements increased in 2009
– 50 colonoscopies
– 35 EGDs
• University of Maryland residents
– 50-55 colonoscopies
– 50 EGDs, including PEG

12. 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

13. Competency
• ASGE: minimum thresholds before
competency can be assessed
– 140 colonoscopies
– 130 EGD
– 200 ERCP
• SAGES: Fulfill RRC requirements
– Privileges granted by local authorities

14. Are numbers important?
• Want proficiency, not familiarity
• Pushback from GI
• Difficulty obtaining privileges

15. 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.

16. Postgraduate Fellowship
• 3 programs with focus on endoscopy
– Louisville
– Miami
– Case Western
• 100-200 colonoscopy
• 200-300 EGD
• 150-200 ERCP

17. How about simulation?

18. 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.

19. 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

20. Physical Models

21. Validation of Physical Simulator
• 21 experienced and 18 novices
• Showed construct validity
Plooy AM, et el. GIE. 2012;76(1):144-50.

24. 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

26. 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

28. 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.

29. 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

30. Intraoperative Endoscopy

31. 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

32. 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.

33. 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.

34. Managing Post op Complications

36. 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.

37. Clips

40. Endoscopic Suturing

41. Endoscopic Suturing

43. Dilating Strictures

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

45. 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

46. 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%

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

49. Endoscopic Innovations in Surgery
• NOTES
• TIF
• BARRX
• Bariatrics
• Resections
• Closure of Perforations
• POEM

50. TIF

51. TIF

52. Before After

53. 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.

54. BARRX

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

60. Endoscopy in Bariatrics

62. Gastrojejunal Barrier

64. Full thickness resection

65. Over the scope clips for GI perforation

69. POEM

73. 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.

74. 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