Therapeutic Endoscopy: Evolution of Use and Utility in Surgical Procedures

A Supplement to

All rights reserved. Reproduction in whole or in part without permission is prohibited. Copyright © 2019 McMahon Publishing Group unless otherwise noted. Therapeutic Endoscopy: Evolution of Use and Utility In Surgical Procedures

Faculty odern endoscopy began in the 1960s, with the introduction of M the fiber-optic endoscope, a breakthrough that turned gastroin- Eleanor C. Fung, MD testinal (GI) endoscopy into a comparatively safe diagnostic procedure Clinical Assistant Professor for the first time.1 Since then, the structure of the flexible endoscope Department of Surgery has remained fundamentally the same, while devices and add-ons Jacobs School of Medicine and Biomedical have been developed to expand its ability.1 What has changed, and is Sciences still changing, according to the surgeons who are advanced flexible University at Buffalo–The State University endoscopists interviewed for this special report, is use of the flexible of New York endoscope as an instrument for therapeutic intervention. Buffalo, New York Jeffrey M. Marks, MD, FACS, Therapeutic Endoscopy in Surgery FASGE For 6 decades, surgeons and gastroenterologists have been Professor of Surgery pushing the boundaries of what can be accomplished with an Director, Surgical Endoscopy endoscope. Surgeons have contributed to the development of key Program Director, Case Western/University procedures in therapeutic endoscopy, including endoscopic sub- Hospitals Cleveland Medical Center mucosal dissection, endoscopic mucosal resection (EMR), endo- Jeffrey L. Ponsky, MD, Professor of Surgical scopic suturing, endoscopic retrograde cholangiopancreatography Education (ERCP), colonoscopy, and polypectomy.1 The development of addi- University Hospitals tional technology and techniques, such as peroral endoscopic myot- Cleveland, Ohio omy (POEM) and endoscopic pyloromyotomy, have advanced the Eric M. Pauli, MD, FACS, FASGE utility of endoscopy beyond evaluation alone and into effective treat- ment (Figure 1).2,3 With each new intervention, the practice of endos- Associate Professor of Surgery Director of Endoscopic Surgery copy has shifted further into the traditional domain of the surgeon. Penn State Health Milton S. Hershey Endoscopy now is a widely accepted option for the surveillance Medical Center and/or treatment of achalasia, Barrett’s esophagus, GI bleeding, Hershey, Pennsylvania and some neoplasms and surgical complications, and is used to inject tumors and place stents.1,4,5 Until recently, therapeutic endos- Michael B. Ujiki, MD, FACS copy was an uncommon specialized skill set among surgeons; how- Vice Chair of Surgery for Innovation and ever, that appears set to change, according to Eric M. Pauli, MD, Program Development an associate professor of surgery and the director of endoscopic Louis W. Biegler Chair of Surgery surgery at Penn State Health Milton S. Hershey Medical Center in Chief of Gastrointestinal Surgery Hershey, Pennsylvania. NorthShore University HealthSystem Evanston, Illinois Dr Pauli identified several factors that are driving surgeon par- ticipation in therapeutic endoscopy: technological and knowledge

Supported by advancements that have expanded the breadth of procedures Advantages of Therapeutic Endoscopy that can be performed; a boost in the numbers of endoscopic procedures, including therapeutic endoscopic procedures, Michael B. Ujiki, MD, FACS, the vice chair of surgery for performed in minimally invasive surgery (MIS) or advanced innovation and program development, Louis W. Biegler Chair gastroenterology fellowships and surgical residencies; and of Surgery, and chief of gastrointestinal surgery at NorthShore growing acceptance that therapeutic endoscopy belongs on University HealthSystem in Evanston, Illinois, calls flexible the spectrum of MIS procedures. endoscopy “an essential tool for surgeons” (Figure 2). Sur- Dr Pauli described the current state of therapeutic endos- geons who are proficient in flexible endoscopy, in addition to Allcopy rights as “both reserved. revolution Reproductionand evolution: revolution in whole for some or in partlaparoscopic without and permission open surgery, is can prohibited. assess a patient’s condi- surgeons and, for others, it’s a period of evolution. tion and wants, and decide with the patient the best approach “For surgeons Copyright who have always © 2019 been McMahon performing thera-Publishingto treatment.Group unless “When you otherwise have a tool boxnoted. and you have multiple peutic endoscopy as part of their practice, what they are see- tools in that tool box—and you’re trained to use all of them— ing is an evolution—a natural progression of disease states, you are going to use whichever tool does the best job for that ideas, and therapies that people have been talking about particular situation,” he said. for decades. But for surgeons who haven’t been doing ther- When appropriate, therapeutic endoscopy offers measur- apeutic endoscopy, there appears to be a revolution hap- able advantages over surgery for patients and health care sys- pening, traced back to NOTES (natural orifice transluminal tems, Dr Ujiki said. Patients recover faster and can avoid an endoscopic surgery). NOTES renewed interest in therapeu- extended length of stay (LOS) in the hospital that would be tic endoscopy because surgeons wanted to perform MIS typical following surgery.7,8 He used the example of esopha- with more advanced procedures, done with smaller tools and gectomy for Barrett’s esophagus, a surgical procedure that equipment.”6 may require an LOS of 7 to 10 days, is associated with multiple Therapeutic endoscopy has supplanted many surgical pro- complications, and may impair a patient’s long-term quality of cedures over the past 3 decades, said Jeffrey M. Marks, MD, life.9,10 In comparison, endoscopic ablation or EMR, performed FACS, FASGE, professor of surgery and director of surgical in appropriate patients, may enable a patient to return home endoscopy at University Hospitals in Cleveland, Ohio. As the list the same day of treatment and avoid the lifelong difficulties that of current endoscopic therapies continues to grow, surgeons’ can arise from removal of the esophagus.11 opinions on endoscopy are beginning to change, he said. “If we can do something with the endoscope or therapeutic “Four decades ago, surgeons didn’t really find much of a endoscopy that we otherwise would need an incision for, and home with flexible endoscopy because it really didn’t have we’re able to perform the same sort of operation endoscopi- a lot of potential for intervention,” Dr Marks said. “But now, cally, it affords great advantage for patient recovery,” Dr Ujiki I think surgeons are starting to realize that many things that said. “There are basically dozens of procedures now that we we do require a skill set in flexible endoscopy in order to do can do with the endoscope that we used to have to do with procedures as well as to manage the complications of the incisions. And so, it has evolved quite significantly a bit over procedure.” the last few years.”

Figure 2. Michael B. Ujiki, MD (center) teaches endoscopy techniques in the Figure 1 . Endoscopic division of the circular simulation setting at NorthShore University muscle fibers of the esophagus during POEM. HealthSystem Grainger Center for Simulation POEM, peroral endoscopic myotomy and Innovation in Evanston, Illinois. Image courtesy of Eric M. Pauli, MD, FACS, FASGE. Image courtesy of Michael B. Ujiki, MD, FACS. 2 Eleanor C. Fung, MD, a clinical assistant professor in the the OR, that likely will turn into a return to the operating room Department of Surgery at Jacobs School of Medicine and in the first 24 hours,” Dr Ujiki said. Biomedical Sciences at the University at Buffalo–The State University of New York in Buffalo, New York, said surgeons Endoscopic Training for Surgeons can draw from both their endoscopic and surgical skills in In 2018, for the first time, all general surgery residents apply- caring for patients and this combination provides advantages ing for certification by the American Board of Surgery were for the patient. required to complete the board’s Flexible Endoscopy Curric- “It’s a bit of a different mentality because we can fuse the ulum and pass the Society of American Gastrointestinal and worldsAll of rightssurgery andreserved. endoscopy Reproduction together,” Dr Fung in said.whole “If or inEndoscopic part without Surgeons permission (SAGES) Fundamentals is prohibited. of Endoscopic you’re only in the surgery world, you’ll keep persisting opera- Surgery examination.13 In surgical fellowships, too, endoscopy tively. If you’re only in the Copyright endoscopy world, © 2019 you’ll McMahon keep persist- Publishingis taking onGroup greater unless significance, otherwise now accounting noted. for a greater ing endoscopically. Whereas for surgeons who do both, we proportion of fellows’ time and procedures in MIS fellowships, can actually combine all the technologies together so that it’s Dr Pauli said. not one or the other. We can use everything to our advantage.” These 2 trends reflect an evolution in the recognition of Endoscopy now accounts for 30% to 40% of her practice, flexible endoscopy as a core skill for general surgeons. It although that figure varies depending on referrals from week to is believed this training will lead to increased utilization of week. Three years after she started practice, she receives many endoscopy in practice. A 2018 study of 58 participants in referrals because she is known as a surgical endoscopist. “A lot the SAGES flexible endoscopy course for fellows showed the of what I do is unexpected because it’s a variable practice where training resulted in long-term practice changes, with partici- I can try a different approach. It’s not one set way to do some- pating fellows maintaining confidence to perform the major- thing. I think that’s where there’s a real benefit; you have a dif- ity of taught endoscopic procedures 6 months later. Fellows ferent mindset in terms of how to attack things,” Dr Fung said. reported no major barriers to implementing endoscopy in The measure of success for an endoscopic procedure is not practice.14 always that a patient avoids surgery, Dr Pauli said. For some “I think this is how therapeutic endoscopy among surgeons patients, endoscopic therapy can help improve or manage begins to move very rapidly and grow very quickly. As more symptoms enough to carry patients through to a surgical pro- surgeons are trained and data continues to come out showing cedure in better condition. “I think that’s where some of the better outcomes, you will find more surgeons seeking out train- genius in these therapeutic procedures lies. While the failure ing, and they will want to add endoscopy to their armamentar- rate may be higher for some of these procedures than with a ium to treat patients,” Dr Ujiki said. definitive surgery, the morbidity of endoscopy is so much less. Surgical endoscopists stress the need for surgeons in It’s certainly worth attempting,” Dr Pauli said. practice to undergo additional training before adopting new endoscopic techniques. Training options, such as mini-fel- Changing Management of Surgical lowships and single- and multiple-day courses, are available Complications through SAGES, the American College of Surgeons, and the American Society for Gastrointestinal Endoscopy (ASGE). Surgeons who perform advanced endoscopy said many sur- These courses are not equivalent to residency or clinical train- gical complications, notably postprocedural bleeds, increas- ing in endoscopy, but they can provide valuable exposure, ingly are being addressed endoscopically. Most bleeding Dr Marks said. “In combination with practice in animal labora- episodes that occur after foregut reconstructions or colorec- tories and endoscopic simulation, these courses will be able tal procedures, with some exceptions in the small bowel, occur to help surgeons gain the skill sets to take on some of these within the reach of an endoscope, according to Dr Pauli. Con- newer procedures.” sequently, many endoscopists have changed their algorithm For practicing surgeons who do not use flexible endoscopy for the treatment of bleeds, relying on endoscopy not just as a or advanced flexible endoscopy, Dr Marks encouraged them first-line, but also a second-line approach to bleeding, he said. to stay abreast of new tools and interventions in endoscopy. “If I scope somebody and they have a rebleed, I’m going to “We’re going to lose our importance when it comes to manag- go back. I know that in the event of a rebleed, I can change my ing diseases if we aren’t right at the forefront with these new algorithm a bit,” he said. “Instead of using a through-the-scope tools,” he said. clip, I can switch to an over-the-scope clip or use an endoscopic sewing machine or something that’s more complex than I did the Putting Therapeutic Endoscopy Into first time around.” Sprays and powders designed to stop bleed- Surgical Practice ing both immediately until other measures can be used for bleed- ing control or to provide permanent hemostasis also have been A practical consideration for surgeons looking to perform introduced, and have shown a benefit in the GI setting.12 “Hav- more therapeutic endoscopy is the challenge of establishing ing a variety of tools at your disposal means that you can ascend a viable practice. A 2008 survey of 1,075 general surgeons that treatment algorithm as you feel necessary,” Dr. Pauli said. showed the proportion of clinicians performing endoscopic Surgical endoscopists strongly recommend that surgeons procedures was inversely correlated with the number of gas- use an endoscope in the operating room (OR) more frequently troenterologists available to patients in the survey area.15 to prevent complications. For instance, during a gastric bypass Many surgeons view therapeutic endoscopy as the subject or sleeve gastrectomy, a surgeon can and should use an endo- of a turf war between gastroenterologists and surgeons, with scope to check the integrity of anastomoses. “That is a very physicians on both sides concerned about potential conse- important aspect of a successful surgery with low complica- quences for referrals, reimbursements, and collegiality. Sur- tions. If there’s a bleeding anastomosis that isn’t recognized in geons who practice therapeutic endoscopy challenge that 3 stereotype, finding that surgeons and gastroenterologists 6 decades. The endoscopist is constrained to a small biopsy often work collaboratively in this growing field to the bene- channel, an endoscope of fixed length, and an inability to tri- fit of patients. angulate.1 “Our limitations of endoscopy now are based on this The ideal therapeutic endoscopy practice involves a partner- coaxial process whereby when we move our hand, we move ship between gastroenterologists and surgeons, and should our eyes or when we move our eyes, we move our hands,” Dr be built based on local considerations, Dr Marks said. In some Marks said. A redesign that would separate the eyes from the places, gastroenterology and surgery interact seamlessly, as hands, mimicking the traditional surgical process, could lessen shown by comanagement of patients and sharing of endos- the learning curve and open up the ability for more surgeons Allcopy rights suites. reserved.In other places, Reproduction specialists perform in whole in individual or in partto perform without complex permission endoscopic is procedures.prohibited. Advances, such silos, a model that is often less successful because there is no as the development of the flexible endoscopic robotic platform, shared learning betweenCopyright the 2 specialties,© 2019 McMahon Dr. Pauli said. Publishing On a may Group provide unlessadditional otherwise benefit to surgeons. noted. “[In] the same way national level, 2 subspecialties—therapeutic endoscopy and that robotics has become a large component of MIS, we have MIS—are becoming more intertwined. This interaction ought the same hopes that flexible robotic platforms would allow us to be reflected at a local level, Dr Fung said. to do intraluminal surgery inside the GI tract better than with “I work in a setting where my colleagues are mainly gas- the flexible endoscope,” Dr Marks said. troenterologists. I’m one of the few surgeons who do a lot of advanced endoscopy in my area,” Dr Fung said. “It should Conclusion never be considered a competition. We all have our different When current challenges are overcome, advanced endos- roles. People working together and fusing our training and skill copists believe the technology will be used in more, and more sets is the best way to go.” complex, procedures including full-thickness resection of GI tract lesions, more organ-sparing procedures, and manage- Current Challenges ment of gallbladder disease. Experts point to multiple barriers that continue to hamper As noted by the expert clinicians interviewed for this special therapeutic endoscopy. Currently, many procedures are not report, as surgeons have more effect on the endoscopy field, reimbursed by insurance or are reimbursed at a low level.16 use of the technique may become commonplace for these A knowledge gap persists about what endoscopy can accom- complex procedures and ones like them. With the development plish safely, an oversight that leads to some patients being of new endoscopic tools and techniques—such as POEM— referred for more invasive surgery when endoscopy would suf- robotic equipment, and hemostatic clips and powders, the aim fice, Dr Ujiki said. Training in advanced therapeutic endoscopy is for these techniques to become safer and more effective. continues to be limited to a minority of surgeons. “When laparoscopy was introduced, it revolutionized surgery,” But the most significant challenges may be technological: Dr Ujiki said. “Endoscopy is the next step where we’ll continue The endoscope device has not evolved significantly in the past to see improved recovery for patients.” References 1. De Groen PC. History of the endoscope. Proc IEEE Inst Electr Electron 10. Fernando HC, Murthy SC, Hofstetter W, et al; Society of Thoracic Eng. 2017;105(10):1987-1995. Surgeons. The Society of Thoracic Surgeons practice guideline series: 2. Inoue H, Minami H, Kobayashi Y, et al. Peroral endoscopic myotomy guidelines for the management of Barrett’s esophagus with high-grade (POEM) for esophageal achalasia. Endoscopy. 2010;42(4):265-271. dysplasia. Ann Thorac Surg. 2009;87(6):1993-2002. 3. Kawai M, Peretta S, Burckhardt O, et al. Endoscopic pyloromyotomy: 11. Haidry RJ, Dunn JM, Butt MA, et al. Radiofrequency ablation and a new concept of minimally invasive surgery for pyloric stenosis. endoscopic mucosal resection for dysplastic barrett’s esophagus and Endoscopy. 2012;44(2):169-173. early esophageal adenocarcinoma: outcomes of the UK National Halo RFA Registry. Gastroenterology. 2013;145(1):87-95. 4. ASGE Standards of Practice Committee, Evans JA, Early DS, et al. The role of endoscopy in Barrett’s esophagus and other premalignant con- 12. Hagel AF, Albrecht H, Nägel A, et al. The application of hemospray in ditions of the esophagus. Gastrointest Endosc. 2012;76(6):1087-1094. gastrointestinal bleeding during emergency endoscopy. Gastroenterol Res Pract. 2017;2017:3083481. 5. Sonnenberg A. Timing of endoscopy in gastrointestinal bleeding. United European Gastroenterol J. 2014;2(1):5-9. 13. Fundamentals of Endoscopic Surgery Program. SAGES Fundamentals of Endoscopic Surgery (FES) required by American Board of Surgery. 6. Yip HC, Chiu PW. Recent advances in natural orifice transluminal endo- www.fesprogram.org/fes-required-american-board-surgery. Accessed scopic surgery. Eur J Cardiothorac Surg. 2016;49(suppl 1):i25-i30. March 11, 2019. 7. Lee JD, Bonaros N, Hong PT, et al. Factors influencing hospital length 14. Kucera W, Nealeigh M, Dunkin B, et al. The SAGES flexible endos- of stay after robotic totally endoscopic coronary artery bypass grafting. copy course for fellows: a worthwhile investment in furthering surgical Ann Thorac Surg. 2013;95(3):813-818. endoscopy. Surg Endosc. 2018 Aug 27. [Epub ahead of print] 8. Swaminathan M, Phillips-Bute BG, Patel UD, et al. Increasing health- 15. Decker MR, Dodgion DM, Kwok AC, et al. Specialization and the cur- care resource utilization after coronary artery bypass graft surgery in rent practices of general surgeons. J Am Coll Surg. 2014;219(1):8-15. the United States. Circ Cardiovasc Qual Outcomes. 2009;2(4): 305-312. 16. Barroso AO. Advanced endoscopy procedures in private practice: is the juice worth the squeeze? Gastrointest Endosc. 2011;74(4): 9. Giwa F, Salami A, Abioye AI. Hospital esophagectomy volume and 913-915. postoperative length of stay: A systematic review and meta-analysis. Am J Surg. 2018;215(1):155-162.

Disclosures: Dr Fung reported no relevant financial conflicts of interest. Dr Marks reported that he is a consultant to Boston Scientific and Olympus. Dr Pauli reported that he is a consultant to, and has received honoraria and speaking fees from Actuated Medical, Bard, Boston Scientific, and Cook; and has received grant/research support from Bard. Dr Ujiki reported that he is a consultant to Apollo Endosurgery, Boston Scientific, Gore Medical, and 2019 Olympus. This special report was sponsored by Cook Medical. Disclaimer: This monograph is designed to be a summary of information. While it is detailed, it is not an exhaustive clinical review. McMahon Publishing, Cook Medical, and the authors neither affirm nor deny the accuracy of the information contained herein. No liability will be assumed for the use of this monograph, and the absence of typographical errors is not guaranteed. Readers are strongly urged to consult any relevant primary literature. Copyright © 2019 McMahon Publishing, 545 West 45th Street, New York, NY 10036. Printed in the USA. All rights reserved, including the right of repro-

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