milestones in gi endoscopy: a pioneer reflects. 1939 the first ... „the six-shooter ......
TRANSCRIPT
Falk Symposium 166GI Endoscopy – Standards & Innovations
18. – 19. September 2008, Mainz
Milestones in GI endoscopy:A pioneer reflects
Nib SoehendraKlinik und Poliklinik für Interdisziplinäre Endoskopie
Universitätsklinikum Hamburg-Eppendorf
Size of the diagnosed gastric early cancer
1950 1960 1970 1980 1990 2000 2010
ZOOMChromoLIFE OCT EUS
Gastrocamera
2-3 cm
Fiberscope
1-2 cm1 cm
Videoscope
0.5 cm
Exera
Lucera NBI,
Micro-, Bio-Endoscopy
ECS
NBI of a tubular adenoma of the colon NBI + Magnification
Narrow Band Imaging (NBI)
Machida H et al. Endoscopy 2004;36:1094-8
ECS (Endo-Cytoscopy System)
Okuyama Y et al. Gastroenterol Endosc 1967;9:42-3Kozu T et al. Gastroenterol Endosc 1975;17:810-7Inoue H et al. Digest Endosc 1996;8:134-8
ECSHigh & Low resolution type
Oral mucosa (magnification 1100x)
Oral mucosa (magnification 450x)
Olympus
Confocal EndomicroscopeInoue H et al. Endoscopy 2000;32:439-43
In vivo study of neoplastic colorectal lesions (with i.v. fluorescein):
• Sensitivity 97.4%
• Specificity 99.4%
• Accurary rate 99.2%Kiesslich R et al. Gastroenterology 2004;127:706-13
Kiesslich R et al. Gastroenterology 2004;127:706-13
Colon cancer. (A) Confocal laser endomicroscopy shows irregular cell architecturewith total loss of goblet cells. (B) Corresponding histologic specimen.
AF Videoscope (2CCDs)AF CCD
Std CCDfor white light
endoscopy
LightGuide
LightGuide
biopsy
Olympus
Optical BiopsyVirtual Histology
Bio Endoscopy
Therapeutic Endoscopy• Foreign body extraction• Bougienage• Pneumatic dilatation• Botox injection• Esophageal stenting• Hemostasis • Variceal obliteration• Band ligation• Antireflux procedures• PEG• Mucosal resection (EMR)• Submucosal dissection (ESD)• Septotomy of Zenker• Klipping of perforation• Sealing of fistula
• Biliary sphincterotomy• Biliary stone extraction• Mechanical lithotripsy• Intraductal lithotripsy• Biliary stenting• Drainage of gallbladder• Pancreatic sphincterotomy• Pancreatic stone extraction (ESWL)• Pancreatic duct stenting• Pseudocyst drainage (EUS guided)• EUS guided neurolysis• Drainage of abscess• Papillectomy• Polypectomy• Colorectal, Duodenal stenting
In the early 90´sThe first rigid endoscopic foreign body removal
Guisez J. Traité des maladies de l‘oesophage. Baillière, 1911Starck H. Lehrbuch der Ösophagoskopie, Kurt Kabitsch 1914
Jackson Ch. JAMA 1921;76:577
Safety-pins in stomach. Peroral gastroscopic removal withoutanesthesia.
1939The first sclerotherapy of esophageal varices
Crafoord C & Frenckner PActa Oto-Laryngologica 1939;27:422-9
Palmer EDThe vigorous diagnostic approach to upper gastrointestinaltract hemorrhage. (1400 patients from 1946-1969)JAMA 1969;207:1477-80
The 1st Consensus Development Conference on Gastrointestinal Endoscopy and 1st Role in Upper
Gastrointestinal Bleeding
Upper gastrointestinal fiberoptic panendoscopy was the most sensitive and specific method to identify the causative lesions and their locations in most patientswith recent or ongoing upper gastrointestinal hemorrhage, to confirm or exclude the presence of clinically suspected lesions, and to evaluate bleedingversus non-bleeding lesions that might be present
Augusta 1980
1976 Injection HemostasisSoehendra N, Werner B.New technique of endoscopic treatment of bleeding gastric ulcer. Endoscopy 1976;8:85-7
Asaki S et al.Endoscopic hemostasis of gastrointestinal hemorrhage by local application of absolute ethanol: a clinical study.Tohoku J Exp Med. 1983;14:373-83
Hirao M et al.Endoscopic local injection of hypertonic saline-epinephrine solution to arresthemorrhage from the upper gastrointestinal tract.Gastrointest Endosc 1985;31:313-7
Chung SCS, Leung JWC et al.Endoscopic injection of adrenaline for actively bleeding ulcers: a randomized trial.Br Med J 1988;296:1631-3
1987
Editorial by Bernard M. SchumanEndoscopic injection therapy for nonvaricealupper gastrointestinal hemorrhage –Is it too good to be true ?
Commenting the paper by:Leung JWC, Chung SCS.Endoscopic injection of adrenalin in bleeding peptic ulcers.Gastrointest Endosc 1987;33:73-5
Endoscopic Hemostatic Methods• Thermal
– Bipolar Coagulation (BICAP)– Heater Probe– APC– Hemostatic forceps (monopolar coagulation)
– (Laser)
• Injection• Mechanical
– Clip – Ligation
Hachisu T. Evaluation of endoscopic hemostasis using an improved clipping apparatus.Surg Endosc 1988;2:13-17
Hachisu T. A new detachable snare for hemostasis in the removal of large polyps or other elevatedlesions.Surg Endosc 1991;5:70-4
1986Cyanoacrylate for controlling variceal bleedingRamond MJ et al. Gastroenterol Clin Biol 1986;10:575
Soehendra N et al. Endoscopy 1986;18:25
Esophageal varices III° Day 4 after 1. EVL
Day 7 after 2. EVL 3 weeks after 2 EVL
1989 Stiegmann GV et al. Endoscopic variceal ligation1996 Saeed ZA et al. „The Six-shooter“
Wolff WI & Shinya HThe first colonoscopic polypectomy was performed at the Beth Israel Medical Center in New York in September 1969Wolff WI, Shinya H. A new approach to colonic polyps. Ann Surg 1973;178:367-78 (report on 499 polypectomies in 350 pts.)
Niwa H8. Kanto Branch Meeting of Japan GE Society
1969 the first polypectomy in the colon
Snare Polypectomy
• Rectum/Colon• Stomach• Esophagus• Duodenum (papillectomy)• Small bowel
Techniques of EMR• Lift and Cut using a double-channel endoscop
(Tada et al. Gastrointest Endosc 1984)
• Suck and Cut using an overtube(Makucchi et al. Jpn J Surg Gastroenterol 1991)
• Suck and Cut using a cap(Inoue et al. Surg Endosc 1990)
• Suck and Cut using single band ligator(Chavez et al. Gastrointest Endosc 1994)
• Simple Snare Resection without any addtional tool(Soehendra et al. Endoscopy 1997)
• Suck and Cut using multiband ligator („DUETTE“) (Soehendra et al. Gastrointest Endosc 2006)
MBL-EMR DeviceDUETTE TM
RF HALO Ablation System, BARRX
En bloc EMR in the Stomach
Courtesy from H. Ono
ESD (Endoscopic Submucosal Dissection)
Endoscopic Submucosal Dissection(ESD)
IT-knife Ono Hook knife Oyama
TT knife Inoe Flex knife Yahagi
Flush knife Toyonaga
UndiffrentiatedAdenocarcinoma
DifferentiatedAdenocarcinoma
Any size<3cmAnysize
>2cm≤2cm
>sm1sm1UL(-/+)
UL(-) UL(+)
T1smT1mDepth of Invasion
Histology
Japanese concensus for EMR Extended indications for EMR
Surgery Clinical trial
Extended Indication for Gastric EMR in Japan
1973 The First Endoscopic PapillotomyKawai K et al. J Kyoto Pref Univ Med 1973;82:353Classen M, Demling L. Med Tribune 1973; 8:27
1983 Endoscopic Papillary Balloon Dilation (EPBD) Staritz M et al. Endoscopy 1983;15:197-8
N 15 ptsSuccessful stone extraction 100 %Mechanical Lithotripsy 44 %
Endoscopic Papillary Balloon Dilation(for removing small stones in patients with coagulopathy)
Endoscopic papillotomy + Balloon sphinteroplasty
for removing large CBD stones(Stone clearance rate: 95%)
Maydeo A, Bhandari S. Endoscopy 2007;39:958-61
Endoscopic extraction of giant CBD stones- Milestones -
• Nakajima N, Akasaka Y, Fukumoto K et al.Peroral cholangiopancreatoscopy (PCPS) underduodenoscopic guidance. Amer J Gastroenterol 1976;66:241-7
• Yamakawa T, Komako F, Shikato J.Biliary tract endoscopes. Gastrointest Endosc 1978;24:110-13
• Koch H, Rösch W, Walz V.Endoscopic lithotripsy in the common bile duct. Gastrointest Endosc 1980;26:16-8
• Demling L, Seuberth K, Riemann JF.A mechanical lithotripter. Endoscopy 1982;14:100-101
• Sauerbruch T, Stern M.Fragmentation of bile duct stones by extracorporeal shockwave lithotripsy. Gastroenterology 1989;96:146-52
My first mechanical lithotripsy
Electrohydraulic Lithotripsy (EHL)
Nakajima N, Akasaka Y, Fukumoto K et al. Peroral cholangiopancreatoscopy(PCPS) under duodenoscopic guidance. Amer J Gastroenterol 1976;66:241-7Koch H, Rösch W, Walz V. Endoscopic lithotripsy in the common bile duct. Gastrointest Endosc 1980;26:16-8
PABLO L. MIRIZZI (1893 - 1964), surgeonCórdoba, Argentina
Mirizzi´s Syndrome is no longer
a surgical indication
Transpapillary intraductal lithotipsy
1976 Naso-biliary drainageNagai N et al. Gastrointest Endosc 1976;23:78-81
Naso-biliary drainage using a 5F catheter
The first endoscopic biliary stenting using a side-viewing gastroscope GF B2 Olympus
1979Endoscopic Biliary StentingSoehendra N, Reynders-Frederix VDtsch med Wschr 1979;104:206
1988: Invention of expandable Metallic Stent
• Gianturco Cook• Wallstent Medivent• Strecker Meditech• Nitinol (memory alloy) Olympus
Irving JD, Adam A, Dick R, Dondelinger RF, LunderquistA., Roche A. Gianturco expandable metallic stents. Result of a European clinical trial (in 16 pts with malignant and 11 ptswith benign strictures). Radiology 1989;172:321
1982 Frimberger E. et al. Spiralprothese für den Gallengang. Dtsch med. Wschr. 1982;107:1985-6
- Z-Stent (Gianturco)- Wallstent- Diamond- Za-Stent- Zilver Stent- Taewoong- Shim-Hanaro- Bonastent- Ella stent- Ecostent
Selfexpandable Metallic Stent
SEMS for palliationof malignant obstruction
• Esophagus• Biliary duct• Gastric outlet• Rectum/Colon• Small bowel
1885The first plastic stent placement in the esophagusSymonds CJ. Transactions of the Clinical Society of London 1885;28:155
Celestin LR. Ann Roy Coll Surg 1959;25:165-70Boyce HW. Geriatrics 1973;28:97Tytgat GNJ et al. Endoscopy 1976;8:180-5Atkinson M, Ferguson R, Parker C. GUT 1978;19:669-71
1983 First metallic stent in the esophagus
Frimberger E. Expanding spiral – a new type of prosthesis for thepalliative treatment of malignant esophageal stenoses. Endoscopy 1983;15:213-4
First biliary metallic stentFrimberger E. Endoscopy 1983;15:213-4
The Nottingham Introducer
Atkinson M, Ferguson R, Parker C. GUT 1978;19:669-71
First endoscopic stent placement in the esophagusTytgat GNJ et al. Endoscopy 1976;8:180-5
1980 The first PEGGauderer MWL, Ponsky JL, Izant RJ Jr.J Pediatr Surg 1980;15:872
1980 Endoscopic ultrasoundDiMagno EP et al. Lancet 1980;1:629-31
EUS equipment to date
Therapeutic EUS• EUS-guided Drainage Cystenterostomy
Grimm H et al. GIE 1992;38:170-1Seifert H et al. Endoscopy 2000;32:255-9Seewald S et al. GIE 2005;62:92-100
• EUS-guided NeurolysisWiersema MJ et al. GIE 1996;44:656-62
• EUS-guided biliary and pancreatic stentingGiovannini M et al. Endoscopy 2001;33:898-900Francois E et al. GIE 2002;56:128-33Tessier G et al. GIE 2007;65:233-41
• EUS-guided gastro-enteroanastomosisFritscher-Ravens A et al. 2003;58:585-91
• EUS-guided antitumortherapyChang KJ Endoscopy 2006;38(S1):S88-93
EUS-guided Cystgastrostomy & Endoscopic Necrosectomy
2002 Endoscopic Endoscopic SuturingSuturing DeviceDeviceSwainSwain CP CP et al. et al. GastrointestGastrointest EndoscEndosc 1986;32:361986;32:36--77
DeMeester
Enteryx
Stretta
Gatekeeper
Endocinch
Shaheen NJ. Gastroenterology 2006;131:952-4
The Rise and Fall (and Rise?) of Endoscopic Anti-Reflux Procedures
50
10
2003 2004 2005 2006
20
30
40
2000 Capsule EndoscopyIddan G et al.Nature 2000;405:417
Double-balloon Enteroscopeprovides therapeutic options
Yamamoto H et al. Gastrointest Endosc 2001;53:216-20
NBI
2007 Single Balloon Enteroscope making enteroscopy simpler?
OLYMPUS SIF Q180
NOTESNatural Orifice Translumenal Endoscopic Surgery
Kalloo AN et al.Flexible transgastric peritoneoscopy: a novel approachto diagnosis and therapeutic intervention in the peritoneal cavity.Gastrointest Endosc 2004;60:114-7
2004-2007Natural Orifice Translumenal Endoscopic Surgery (NOTES)
Animal experimentsKalloo AN et al. Flexible transgastric peritoneoscopy: a novel approach to diagnosis and therapeutic intervention in the peritoneal cavity. Gastrointest Endosc 2004;60:114-7Jagannath et al. Peroal transgastric endoscopic ligation of fallopian tubes with long-term survival in a porcine model. Gastrointest Endosc 2005;61:449-53Wagh MS et al. Endoscopic transgastric abdominal exploration and organ resection: initialexperience in a porcine model. Clin Gastroenterol Hepatol 2005;3:892-6Park PO et al. Experimental studies of transgastric gallbladder surgery: cholecystectomy and cholecystogastric anastomosis. Gastrointest Endosc 2005;61:601-6Kantsevoy SV et al. Endoscopic gastrojejunostomy with survival in a porcine model.Gastrointest Endosc 2005;62:287-92Pai RD et al. Transcolonic endoscopic cholecystectomy: a NOTES survival study in a porcine model. Gastrointest Endosc 2006;64:428-34Lima E et al. Transvesical endoscopic peritoneoscopy: a novel 5 mm port for intra-abdominal scarless surgery. J Urol 2006;176:802-5Sumiyama K et al. Transesophageal mediastinoscopy by submucosal endoscopy withmucosal flap safety valve technique. Gastrointest Endosc 2007;65:679-83
Source: Gastrointest Endosc 2005
NOTES: Creation of a gastroenterostomy
2004-2007Natural Orifice Translumenal Endoscopic Surgery (NOTES)
in human
Kalloo AN et al. Flexible transgastricperitoneoscopy: a novel approach to diagnosis and therapeutic intervention in the peritoneal cavity. Gastrointest Endosc 2004;60:114-7
Raddy N & Rao VG. Trangastric Appendectomy
Transvaginal endoscopic cholecystectomy (Strassburg, New York, Sao Paulo, ….)
Natural orifice
Zornig C et al. Endoscopy 2007;39:913-5
Hybrid transvaginal transumbilical NOTES
The dream of GI endoscopists
WWW.noscar.org.
Thank you !
President: Prof. Dr. N. SoehendraNOVEMBER 7-8, 2008
CONGRESSCENTRUMHAMBURGwww.endoclubnord.com