THERAPEUTIC ENDOSCOPY IN GI SURGERY PRESENTER : Dr . Sumit Sudhir Hadgaonkar MODERATOR : 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 EndoscopyFIRST 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
Upper GI Small bowel TherapeuticBilio-pancreatic Lower GI
Upper GI endoscopy:Variceal bleed Nonvariceal bleedTherapeutic 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 ligationEndoscopic 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 3-4sites•1-2cm away frombleeding vessel•Inject 5-10ml at eachsite
Laser: Electric current:• Argon laser is not useful • Monopolar: several in severe bleeding thousand degree of• Disadvantages: heat1. Risk of full thickness • Disadv: Full thickness injury (tremendous damage heat) • Bipolar:2. Expensive heat- 100degree C3. Lack of portability Will induce coaptation Overall 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 healsBand 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 dilator1) 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 stentsSelf 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 cardia1)Balloon dilatation:short term success (<6 months in 75% of patients)Repeated dilatation is required2) Endoscopic injection of botulinum into LES:Less inflammation & fibrosis than repeated dilatationBut results not durableInitially effective in 60-85% of patients 50% recurrence
Induces severe fibrosis at GE junction difficult formyotomy 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 reflux3) 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:
CholedocholithiasisSphincter of oddidysfunctionAcute cholangitisAcute gall stonepancreatitisEndoprosthesisinsertion
Endoscopic biliary stents Metallic stents Plastic stents• Self expanding • Straight flaps at each end• Put in collapsed state (9F) for easy insertion• After release (30F) • Short lived ,require change• Long lived every 3-6 months• Less prone to sludge • Removal easy• Danger of becoming irremovable
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) Colonoscopy1) 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 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
• 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
• Colonic decompression Useful in Ogilvies 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
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 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)
PROCEDURES DESCRIBED TILL NOWHuman 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