■ COLLEGE LECTURES Digestive endoscopy in five decades Peter B Cotton ABSTRACT – The world of gastroenterology scopy. So-called semi-flexible gastroscopes were changed forever when flexible endoscopes cumbersome and used infrequently by only a few became available in the 1960s. Diagnostic and enthusiasts. therapeutic techniques proliferated and entered the mainstream of medicine, not without some Diagnostic endoscopy controversy. Success resulted in a huge service demand, with the need to train more endo- The first truly flexible gastroscope was developed in 1 This paper is scopists and to organise large endoscopy units the USA, following pioneering work on fibre-optic 2 based on the Lilly and teams of staff. The British health service light transmission in the UK by Harold Hopkins. Lecture given at struggled with insufficient numbers of consul- However, commercial production of endoscopes was the Royal College tants, other staff and resources, and British rapidly dominated by Japanese companies, building of Physicians on endoscopy fell behind that of most other devel- on their earlier expertise with intragastric cameras. 12 April 2005 by oped countries. This situation is now being My involvement began in 1968, whilst doing bench Peter B Cotton addressed aggressively, with many local and research with Dr Brian Creamer at St Thomas’ MD FRCP FRCS, national initiatives aimed at improving access and Hospital, London. An expert in coeliac disease (and Medical Director, choice, and at promoting and documenting jejunal biopsy), he opined that gastroscopy might Digestive Disease quality. Many more consultants are needed and become useful and legitimate only if it became pos- Center, Medical some should be relieved of their internal medi- sible to take target biopsy specimens – since no one University of South Carolina, cine commitment to focus on their specialist seriously believed what endoscopists said that they Charleston, USA skills. New instruments and procedures are saw. Shortly afterwards, Truelove’s group in Oxford stretching the diagnostic boundaries and described their experience with the first Olympus Clin Med changing the interface with sister disciplines like side-viewing gastroscope with biopsy capability.3 We 2005;5:614–20 radiology, surgery and pathology. The old dis- obtained an instrument and a career was launched. tinctions, particularly between gastroenterology Views and photographs were remarkably good. and surgery, are increasingly irrelevant and Gastric ulcers and their risk of malignancy were a unhelpful. The future is bright for gastroen- major concern at that time, so gastroscopy became terology and for endoscopy, but unpredictable. In accepted relatively quickly. Gastroenterologists in the this fast-changing world it will be essential to West pressed manufacturers to produce forward- remain flexible, with our goals firmly focused on viewing instruments, which allowed examination of the best interests of our patients. the oesophagus and duodenum, as well as the stomach. There followed a series of articles from KEY WORDS: accountability, diagnostic endoscopic enthusiasts claiming that endoscopy was endoscopy, digestive surgery, fibre-optics, more accurate than the standard barium meal in the pathology, quality, radiology, therapeutic context of dyspepsia, bleeding and the operated endoscopy, training stomach. These studies were somewhat flawed since the findings at endoscopy were used as the gold stan- dard!4,5 Endoscopy gradually became the first-line The practice of digestive medicine changed irrevo- investigation for most patients with suspected upper cably with the introduction of commercial flexible digestive disease. This evolution was not without its fibre-optic endoscopes in the 1960s. Gastro- skeptics, especially those who believed (perhaps based enterology at that time was a simple contemplative on unfortunate experiences with rigid esophago- endeavour. Many digestive complaints were attrib- scopy) that it was dangerous to attempt passage of an uted to stress and treatments were restricted to diet, endoscope without barium confirmation of a patent antacids and bed rest. Diagnosis relied on clinical oesophagus. acumen, aided by barium studies and analyses of gas- The first attempts at flexible sigmoidoscopy and tric acid and faecal fat. Jejunal biopsy and liver colonoscopy were reported in the late 1960s,6 and biopsy (and exploratory laparotomy) were the only included some bizarre athletic adventures.7 invasive diagnostic procedures. Endoscopy was lim- Improvements in the flexibility of instruments and ited to rigid proctoscopy and occasional esophago- the developing skills of some experts eventually 614 Clinical Medicine Vol 5 No 6 November/December 2005 Digestive endoscopy in five decades allowed fairly routine colonoscopy. At that stage there was no were dubious if not dismissive of their younger colleagues who thought that colonoscopy would become a primary diagnostic embraced ‘technical’ rather than ‘cognitive’ pursuits. Chris tool. Booth, President of the British Society of Gastroenterology Endoscopic retrograde cholangiopancreatography (ERCP) (BSG), asked ‘Will the gastroenterologist become merely a tech- was an extraordinary development at a time when biliary and nician?’ Solly Marks made the same point, but with character- pancreatic diseases were diagnosed with palpation, plain radi- istic humor, when he said ‘Consider the whole patient, not just ographs and laparotomy. There were no scans and percutaneous the hole in the patient’. The disinterest of the BSG leadership led transhepatic cholangiography was used in very few centres. The to the formation of a separate endoscopy society – the British first description of endoscopic cannulation of the biliary or pan- Society for Digestive Endoscopy.18 This effectively fostered the creatic duct appeared in 1968 in the USA, but included no data endoscopic child in the UK, but further aggravated the schism or radiographs.8 The watershed came when Japanese groups with the establishment. worked with endoscope manufacturers to produce purpose- designed instruments. Presentation of some ERCP pictures at Burden of success Digestive Disease Week in 1970 caused a sensation. I was fortu- nate enough to spend 2 weeks with Dr Kazuei Ogoshi in Niigata The third decade – from the mid-1980s – was a period of consol- in 1971, and I brought the technique back to Britain.9 It has idation and widespread dissemination. Diagnostic and thera- been the main focus of my clinical life and research ever since. peutic endoscopy became broadly accepted and spread to the far corners of the earth. Endoscopy societies sprang up in most coun- Therapeutic endoscopy tries. Paradoxically, the British Society for Digestive Endoscopy (under my presidency) decided to disband in 1980 and was folded If diagnostic endoscopy was exciting, the subsequent therapeutic back into its parent organisation, the BSG.19 The reason for this revolution was truly amazing. The decade from the early 1970s was simple: I believed, and the membership agreed, that saw the rapid development of a host of endoscopically based endoscopy is a tool to be used by digestive specialists, not a treatments, including the management of oesophageal obstruc- specialty of its own. tion, foreign bodies and acute gastrointestinal bleeding.10,11 The obvious success of endoscopy brought heavy responsibil- Colonoscopic polypectomy was truly a breakthrough in col- ities and significant frustration. There was an insatiable demand orectal medicine.12 Therapeutic ERCP revolutionised the man- for teaching and an urgent need to develop efficient endoscopic agement of biliary obstruction, with the introduction of biliary services. What started as an occasional toy had become a major sphincterotomy for removal of stones13 and the use of plastic commitment. We struggled to develop endoscopy units, to train stents to relieve jaundice.14 Percutaneous endoscopic gastrostomy endoscopy nurses and to establish appropriate professional sup- soon followed.15 port structures. A gross shortage of consultants, the distractions of private practice, the ever present commitment to acute gen- Establishment resistance eral medicine and the severe lack of resources made it impos- sible to provide services of high quality. Reports documenting It is difficult to overstate the impact of this barrage of endo- the urgent needs were largely ignored. These frustrations led to scopic therapy. Embraced rapidly by young and enthusiastic my move to the USA in 1986, after reflection during a 6-month endoscopists, it was questioned by many academic gastro- ‘sabbatical’. enterologists and seriously resisted (even resented) by much of the surgical community. For instance, erudite studies concluded Current status and developments that endoscopy for acute gastrointestinal bleeding was not worthwhile since it did not seem to improve outcomes. To me Digestive endoscopy has continued to evolve over the past two this seemed illogical. If a better diagnostic process did not decades. I will discuss three main streams of change – endo- improve outcomes, it was time to develop better treatments; scopic advances, developments in related fields and the indeed, endoscopic haemostasis soon became available and increasing focus on quality and accountability. widely accepted. There was resistance to biliary sphincterotomy and much misleading literature from people comparing apples Endoscopic advances with oranges.16 The then President of the Royal College of Surgeons, Sir