THERAPEUTIC ENDOSCOPY IN GI SURGERY

my much praised seminar presentation. i hope it will help other endoscopy aspirants.

1. THERAPEUTIC ENDOSCOPY IN GI SURGERY PRESENTER : Dr . Sumit Sudhir Hadgaonkar MODERATOR : Prof. G.S.Moirangthem

2. 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.

3. History of Endoscopy FIRST ENDOSCOPE by Philip Bozzini 1806 ‘Lichtleiter

4. 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.

5. Electronic (charge coupled device) endoscpe developed in 1983. Thus the modern endoscope was born. Kurt Semm , a gynecologist , regarded as father of Modern Endoscopy.

6. 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

7. Parts of Endoscope

8. Complete Endoscope Assembly

9. Types of endoscopy

10. 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

11. Endoscopic treatment options: Injection therapy Thermal therapy Endoscopic clipping Endoscopic band ligation Endoscopic hemostasis should be followed by omeprazole infusion therapy for prevention of rebleeding from NBVV/ adherent clot

12. 1) Injection therapy: Sclerosants : Epinephrine (alone or with saline) Absolute alcohol Thrombin in NS Sodium tetradecyl sulfate Polidocanal Efficacy – 90% with very low complications

13. Method: 4mm 23G needle Submucosally at 3-4 sites 1-2cm away from bleeding vessel Inject 5-10ml at each site

14. Thermal therapy: Laser Electric current 1) Laser argon laser Nd -YAG laser

15. Laser: Argon laser is not useful in severe bleeding Disadvantages: Risk of full thickness injury (tremendous heat) Expensive Lack of portability Electric current: Monopolar : several thousand degree of heat Disadv : Full thickness damage Bipolar: heat- 100degree C Will induce coaptation Overall success rate: 80-95% Rebleed rate: 10-20% Perforation rate: 0.5%

16. 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.

17. Variceal bleeding 30% mortality even in hospitalisation . Rebleeding is significant in those 2/3 rd 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)

18. 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 2 nd session performed 5 days later Repeated at 1-3 weeks interval till all varices are ablated.

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

20. 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

21. Indications: Failure of objects to move for 48-72 hours Objects wider than 2cm or longer than 5cm Signs of respiratory compromise Inability to handle secretions

22. 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.

23. 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

24. 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)

25. 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

26. Types of dilators: Guide-wire type Balloon type 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

27. Disadv : Direct visualization of dilatation process not possible Provides both axial and radial force Suitable for tight strictures

28. 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)

29. 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.

30. Types of stents Self expanding metalic stent(SEMS) Permanent Passed through working channel of colonoscope over delivery cathether OR Over fluroscopically placed guidewire

31. Silicone stent: Removable Used for benign strictures

32. 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

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

34. Treatment of achalasia cardia

35. Endoluminal treatment of GERD: Recently introduced in USA. Still under process of approval by FDA Endoclinch : Sutures placed intramucosaly only at GE junction (circumferentially) Overtube placement with 2 gastroscopes 1 st gastroscope 2 nd gastroscope suction suture device suture cutting – knot tying

36. 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.

37. 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.

38. 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%.

39. 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:

40. 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

41. 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

42. Pancreatic Stents Smaller in caliber than biliary stents Have side holes for drainage

43. 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

44. 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

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

46. 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.

47. Endoscopy for lower GI tract Flexible sigmoidoscopy 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

48. 2) Colonoscopy: Therapeutic uses : Hemostasis: Recent severe but currently inactive bleeding Stigmata of recent hemorrhage such as active bleeding, adherent clot, nonbleeding visible vessel Hemostasis achieved in same manner as UGIT Angiodysplasia and diverticulosis (MC cause of lower GI bleeding) Thermal techniques should be used with caution in proximal colon for hemostasis

49. Polypectomy Most polyps >1cm are easily seen over colonoscope All colon visualization is necessary Polypectomy snare used for removing polyp Electrocautery used for Hemostasis Extremely large polyps- >1 session Ulcerated sessile indurated polyps may be malignant and best removed by surgery

50. Colonic decompression Useful in Ogilvie's syndrome colonic volvulus sigmoid volvulus But decompression is not a definitive procedure- buys time for bowel preparation for elective surgery. Mucosa can be visualized for viability Recurrence common

51. 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.

52. RECENT ADVANCES Natural 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.)

53. PROCEDURES DESCRIBED TILL NOW Laboratory reports Cholecystectomy , Splenectomy , Tubal ligation, Gastrojejunostomy Pyloroplasty , Staging peritoneoscopy , Liver biopsy, Distal pancreatectomy , Ventral hernia repair, Gastric sleeve resection , Colectomy (right and left)

54. PROCEDURES DESCRIBED TILL NOW Human cases TG- appendectomy, TV- cholecystectomy , TG- cholecystectomy , TG- gastro- enterostomy , Cancer staging

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

56. ADVANTAGES: No wound infection No incision hernia No post op adhesions

57. Can be ‘Future of Surgery’ from -Minimal invasive surgery to -Least invasive surgery

58. Thanking you Thanking you Thanking you