THERAPEUTIC ENDOSCOPY IN GI SURGERY

PRESENTER : Dr . Sumit Sudhir HadgaonkarMODERATOR : Prof. G.S.Moirangthem

WHAT IS ENDOSCOPY ???• Endoscopy Greek Word “Endo”means “Inside” “Skopeein ”means “To See”

• Examination of the interior of a canal or hollow viscus by means of a special instrument, such as an endoscope.

• Direct viewing interior of an organ is often very

helpful in determining the cause of a problem & helpful in establishing a diagnosis.

History of Endoscopy

FIRST ENDOSCOPE by Philip Bozzini 1806

‘Lichtleiter

• 1822 William Beaumont ,first introduced into human being.

• Maximilian Nitze ( 1848 – 1906) modified Edison`s light bulb and created the first electrical light bulb for using it for urological procedures

• Decelopement of first fiberoptic endoscope by Basil Hirschowitz in 1958.

• Electronic (charge coupled device) endoscpe developed in 1983.

• Thus the modern endoscope was born.

• Kurt Semm , a gynecologist , regarded as father of Modern Endoscopy.

Historical Landmarks in GI Endoscopy

• 1968-Endoscopic Retrograde pancreatography• 1969-Colonoscopic polypectomy• 1970-Endoscopic Retrograde cholangiography• 1974-Endoscopic Sphincterotomy• 1979-Percutaneous Endoscopic Gastrostomy• 1980-Endoscopic Injection Sclerothrapy• 1980-Endoscopic ultrasound• 1985-Endoscopic control of Upper GI bleeding• 1990-Endoscopic Variceal Ligation

Parts of Endoscope

Complete Endoscope Assembly

Types of endoscopy

DiagnosticTherapeutic

Upper GI Small bowel

Bilio-pancreatic

Lower GI

Therapeutic

Upper GI endoscopy: Variceal bleed Nonvariceal bleed

Therapeutic endoscopy in nonvariceal bleeding• Stabilization first and then endoscopy.• UGIE sensitive in 80-95% of cases• Spontaneously stop in 70-85% (without

coagulopathy) without further intervention

Endoscopic treatment options:1. Injection therapy2. Thermal therapy3. Endoscopic clipping4. Endoscopic band ligation

Endoscopic hemostasis should be followed by omeprazole infusion therapy for prevention of rebleeding from NBVV/ adherent clot

1) Injection therapy:• Sclerosants:

1. Epinephrine (alone or with saline)2. Absolute alcohol3. Thrombin in NS4. Sodium tetradecyl sulfate5. Polidocanal

• Efficacy – 90% with very low complications

Method:

•4mm 23G needle

•Submucosally at 3-4 sites

•1-2cm away from bleeding vessel

•Inject 5-10ml at each site

Thermal therapy:1. Laser 2. Electric current

1) Laser argon laser Nd-YAG laser

Laser:• Argon laser is not useful

in severe bleeding• Disadvantages:1. Risk of full thickness

injury (tremendous heat)

2. Expensive3. Lack of portability

Electric current:• Monopolar: several

thousand degree of heat

• Disadv: Full thickness damage

• Bipolar: heat- 100degree CWill induce coaptationOverall success rate: 80-

95%Rebleed rate: 10-20%Perforation rate: 0.5%

Endoscopic clipping:• One clip at one site- usually fall of in 7-10 days when

bleeding site heals

Band ligation:• Only possible in small sized nonfibrotic acute peptic

ulcer bleeding.

Variceal bleeding• 30% mortality even in hospitalisation.• Rebleeding is significant in those 2/3rd who survive

first bleeding attack.• Stabilisation of patient first.• Vasopressin infusion• Sengstaken Blackmore tube (12-24 hours before

sclerotherapy)• Endoscopy: Sclerotherapy EVBL(endosopic variceal band ligation)

Sclerotherapy:• Mostly preferred- sodium tetradecyl sulfate• For gastric varices start injection lust above GD

junction and move proximally• Intravariceal injection is better than perivariceal• 20ml is total amount in one session• 2nd session performed 5 days later• Repeated at 1-3 weeks interval till all varices are

ablated.

EVBL• Therapy of choice for variceal bleeding• Requires expertise• Lower complication rates

Foreign body extraction:

• Ingested mostly by 2 groups- children (1-5 years) adults (inebriated or

psychiatric patients or prisoners)

• 80-90% will pass spontaneously

• 1% will require surgical intervention

Indications:1. Failure of objects to move for 48-72 hours2. Objects wider than 2cm or longer than 5cm3. Signs of respiratory compromise4. Inability to handle secretions

• Coins are most frequently the foreign body in children

• Removed with adequate sedation and patient in trendelenberg position

• Coin grasped with polypectomy snare or tenaculum forcep

• If coin is in stomach it will pass through.

• Meat impaction – MC foreign body• Removed if >12hours• Even though bolus passes through esophagoscopy is

necessary to R/O any obstruction• Sharp objects though small should be removed

• Ingested button batteries are harmful to esophagus and stomach (other parts passes readily)

• Only foreign body which should never be removed endoscopically- coccaine filled packs (risk of breakage)

Esophageal Stricture dilatation

• Patients presenting with dysphagia or odynophagia• Barium swallow is done before endoscopy- structure

and length and stricture• Endoscopy- to identify lesion and biopsy• Benign peptic ulcer stricture- MC• 90% of peptic and radiation strictures- amenable to

dilatation• Goal- dilate up to 14-15mm (45F)• Dilatation done in multiple sessions

Types of dilators:1. Guide-wire type2. Balloon type3. Optical dilator

1) Guide-wire dilator:• Rigid device made of PVC• Metal olive (Eder-Puestow) and mercury filled

dilators are obsolete now• Has a hollow core and passed over endoscopic or

fluoroscopic guide-wire

• Disadv: Direct visualization of dilatation process not possible

• Provides both axial and radial force• Suitable for tight strictures

Balloon type• Can be passed through endoscopic

endoscope’s therapeutic channel• Dilatation process directly visualized • Has been tried for corrosive strictures (but

rate of rupture increased)

Optical dilator:• Similar to guide wire type• But gastroscope can be passed through core

enabling visualization of dilatation process.• Malignant strictures due to unresectable

tumors/ TEF require palliative dilatation and placement of stents.

Types of stents

Self expanding metalic stent(SEMS)

• Permanent• Passed through working

channel of colonoscope over delivery cathether

OR• Over fluroscopically

placed guidewire

Silicone stent:• Removable• Used for benign

strictures

Percutaneous endoscopic gastrostomy (PEG) and jejunostomy(PEG-J)

• Preferred method of enteral feeding for patients: unable to swallow chronic gastric compression supplemental nutrition• These are less expensive, less invasive and safe than

surgical gastrostomy• Contraindication: Total esophageal obstruction Massive ascites Intraabdominal sepsis

• PEG-J placement is done by extension of PEG.• By passing a jejunal tube through PEG.• Indications: Gastroparesis Severe gastroesophageal reflux

Treatment of achalasia cardia

1)Balloon dilatation:

short term success (<6 months in 75% of patients)

Repeated dilatation is required

2) Endoscopic injection of botulinum into LES:

Less inflammation & fibrosis than repeated dilatation

But results not durable

Initially effective in 60-85% of patients 50% recurrence

Induces severe fibrosis at GE junction difficult for myotomy later

Endoluminal treatment of GERD:• Recently introduced in USA.• Still under process of approval by FDA1) Endoclinch:• Sutures placed intramucosaly only at GE junction

(circumferentially)• Overtube placement with 2 gastroscopes 1st gastroscope 2nd gastroscope suction suture device suture cutting – knot tying

2) Plicator: • Also a suture based technique to create a full

thickness flap at GE junction.• Serves as a barrier against reflux

3) Stretta: • Blindly performed after localisation of LES

endoscopically• Delivery of radiofrequency ablation into LES and

inducing collagen deposition to LES• Thus adding more bulk and reducing compliance of

LES.

Endoscopic Mucosal Resection(EMR)

• EMR is an endoscopic technique developed for removal of sessile or flat neoplasm confined to the superficial layers (mucosa and submucosa) of the GI tract.

• EMR cap method used to perform• Effective treatment for Squamous cell carcinoma

esophagus• When used for Barrett’s esophagus 30% develop

recurrence within 2 years.• EMR is widely used for resection of flat benign colon lesions. Use for malignant polyps is questioned.

Endoscopic Submucosal Dissection(ESD)

• ESD has been developed for en bloc removal of large (usually more than 2 cm), flat GI tract lesions.

• Use less established for colonic lesions• Use justified in stomach and esophageal cancers

when restricted to mucosa. (around 3% lymph node positivity)

• 5 year survival rate for m1-m2 lesions around 95%.

Endoscopy for pancreatobiliary tree:• Willium McKune introduced in 1968• Endoscopic sphincterotomy described by German

and Japanese surgeons.

Endoscopic sphincterotomy:• Sphincterotome consists of standard canula

contaning wireloop 2-3cm of which is exposed near tip.

Indication:

Choledocholithiasis

Sphincter of oddi dysfunction

Acute cholangitis

Acute gall stone pancreatitis

Endoprosthesis insertion

Endoscopic biliary stents

Metallic stents• Self expanding• Put in collapsed state (9F)• After release (30F)• Long lived• Less prone to sludge• Danger of becoming

irremovable

Plastic stents• Straight flaps at each end

for easy insertion• Short lived ,require change

every 3-6 months• Removal easy

Indications of biliary stenting:

• Malignant strictures of CBD –favorable for lesion below bifurcation

• Benign strictures due to iatrogenic trauma or due to penetrating trauma

• Sclerosing cholangitis• Choledochocoele

Pancreatic Stents

• Smaller in caliber than biliary stents• Have side holes for drainage

Indications for pancreatic stenting

• Bypass ductal leaks and strictures• Pancreatic divisum-for minor papilla stenting• Pancreatic fistula• Pancreatic pseudocyst – when cyst in connection

with main pancreatic duct

Small Bowel Enterosopy• Obscure GI bleeding is most common indication • Best performed at laparotomy by telescoping small

bowel• Noninvasive techniques will make diagnosis in only

50% cases

• Double balloon endoscopy (DBE) introduced in 2000 for examination of entire small bowel non invasively

• But DBE is labor intensive procedure and may take 1-3 hours

• capsule endoscopy , a substitute for small bowel Enteroscopy.

• But diagnostic yield is 50-60% for recent bleeding and far lower for remote bleeding.

Endoscopy for lower GI tract1) Flexible sigmoidoscopy2) Colonoscopy

1) Flexible sigmoidoscopy:• Majority of indications are for malignancy only• Very few therapeutic indications are: Detorsion of sigmoid volvulus Foreign body removal Distal stricture management

2) Colonoscopy:Therapeutic uses:• Hemostasis:Recent severe but currently inactive bleedingStigmata of recent hemorrhage such as active

bleeding, adherent clot, nonbleeding visible vesselHemostasis achieved in same manner as UGITAngiodysplasia and diverticulosis (MC cause of lower

GI bleeding)Thermal techniques should be used with caution in

proximal colon for hemostasis

• PolypectomyMost polyps >1cm are easily seen over colonoscopeAll colon visualization is necessaryPolypectomy snare used for removing polypElectrocautery used for HemostasisExtremely large polyps- >1 sessionUlcerated sessile indurated polyps may be malignant

and best removed by surgery

• Colonic decompression Useful in Ogilvie's syndrome colonic volvulus sigmoid volvulusBut decompression is not a definitive procedure-

buys time for bowel preparation for elective surgery.Mucosa can be visualized for viabilityRecurrence common

Stricture dilatation• Anastomotic stricture offer best result• Balloon dilators most commonly used• Endoscopic Nd- YAG laser used for malignant

obstruction allowing recanalisation• Stenting of malignant obstruction is appealing

method.

RECENT ADVANCESNatural Orifice Trans Endoscopic Surgery

(NOTES) :• PERFORMING SURGICAL PROCEDURES WITHOUT

MAKING INCISIONS ON THE SURFACE OF THE BODY and LEAVING NO SCARS

• An experimental surgical technique- scar less abdominal operations performed with an multi-channel endoscope passed through a natural orifice (mouth, urethra, anus, vagina etc.)

PROCEDURES DESCRIBEDTILL NOW

• Laboratory reportsCholecystectomy, Splenectomy,Tubal ligation, GastrojejunostomyPyloroplasty,Staging peritoneoscopy, Liver biopsy,Distal pancreatectomy,Ventral hernia repair,Gastric sleeve resection,Colectomy (right and left)

PROCEDURES DESCRIBEDTILL NOW

Human cases• TG- appendectomy,• TV- cholecystectomy,• TG- cholecystectomy,• TG- gastro-enterostomy,• Cancer staging

• Internal incision is over stomach, vagina, bladder or colon, thus completely avoiding any external incisions or scars.

ADVANTAGES:

• No wound infection• No incision hernia• No post op adhesions

Can be ‘Future of Surgery’ from -Minimal invasive surgery

to -Least invasive surgery

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