Surgeons are proficient at endoscopy when properly trained. Endoscopy training should focus on achieving proficiency rather than a minimum number of procedures. Proficient surgical endoscopists can provide comprehensive care to GI surgery patients through techniques like intraoperative endoscopy, managing postoperative complications, and new procedures like TIF and POEM. Endoscopy will continue to be an important part of GI surgical practice.

1. Flexible Endoscopy:
The Surgical Perspective
Jonathan Pearl, MD

2. History of Surgical Endoscopy

3. Kelly, 1895 Hirschowitz, 1957

4. McCune, 1968 Shinya, 1968

5. History
• Kelly, 1895, sigmoidoscopy
• McCune, 1968, ERCP
• Shinya and Wolf, 1975, polypectomy
• Sugawa, 1975, Endoscopic treatment of UGIB
• Ponsky, 1975, colonoscopic tattooing
• Ponsky and Gauderer, 1979, PEG
• Stiegman, 1980, band ligation

6. Endoscopy Volume
• 2434 surgeons sitting for recertification 1995-
1997
• Average number of total procedures: 400
• 51 (13%) endoscopic procedures
– 21 Colonoscopy
– 15 EGD
– 3 PEG
– Flex sig, bronch
Ritchie, WP et al. Ann Surg. 1999; 230(4): 533.

7. Endoscopy Volume
• 10-year update
– 4968 recertifying surgeons, 2007-2009
• 533 annual procedures
• Endoscopy procedures
–Urban surgeons: 39
–Rural surgeons (large population): 214
–Rural surgeons (small population): 320
Valentine RJ, et al. Ann Surg. 2011; 254(3):520-6

8. Surgeons do Endoscopy Well
• 13,580 surgeon-performed colonoscopies
• Prospective database
• 92% completion rate
• 34% polyp detection rate
• Low rates of complications
– 10 bleeds, 10 perforation
• Experience matters
– Higher completion rates with >100/yr
Wexner et at. Surg Endosc. 2001; 15(3); 251-261.

9. Surgeons do Endoscopy Well
• 558 colonoscopy patients in VAMC
• All colonoscopies performed by colorectal
surgeons
• Surgeons met all standard quality measures
– 99% performed for ASGE-approved indication
– 97% cecal intubation rate
– Adenoma detection rate 26%
– 1 post-polypectomy bleed, 1 perforation
Tran Cao HS, et al. Surg Endosc. 2009. 23:2364-8

10. Navy Data
• 566 colonoscopies by colorectal and general
surgeons
• 97% cecal intubation
• 27% adenoma detection
• No perforation
• No post-polypectomy bleed

11. Training Requirements
• RRC Requirements increased in 2009
– 50 colonoscopies
– 35 EGDs
• University of Maryland residents
– 50-55 colonoscopies
– 50 EGDs, including PEG

12. Position Paper
• ASGE, ACG, AGA
• Concerns about ABS training numbers
– “…inadequate especially when surgical residents
are required to perform only a fraction of the
procedures requires to assess competency”
– Places undue burden on GI to achieve numbers

13. Competency
• ASGE: minimum thresholds before
competency can be assessed
– 140 colonoscopies
– 130 EGD
– 200 ERCP
• SAGES: Fulfill RRC requirements
– Privileges granted by local authorities

14. Are numbers important?
• Want proficiency, not familiarity
• Pushback from GI
• Difficulty obtaining privileges

15. Surgical Endoscopy Program
• Single center instituted a dedicated surgical
endoscopy program for residents
– 2 dedicated days
– Residents at all levels
– 4 year retrospective review
• Avg scopes 1999 graduates: 21
• Avg scopes 2005 residents: 161
Morales MP, et al. Surg Endosc. 2008. 22(9)2013-7.

16. Postgraduate Fellowship
• 3 programs with focus on endoscopy
– Louisville
– Miami
– Case Western
• 100-200 colonoscopy
• 200-300 EGD
• 150-200 ERCP

17. How about simulation?

18. VR Simulation
• Early data discouraging
– Construct validity of VR simulators
– GI Fellow training
• 10 hours of simulation training
– Useful for familiarization with equipment and
technique
– No clinical difference after 15 colonoscopies
Cohen J, et al. GIE. 2006; 64:361-8.

19. VR Simulation
• 36 trainees randomized to simulator training
vs clinical training
– 16 hours simulation training vs 16 hours patient-
based training
– After training tested on simulator then 3 clinical
cases
– Simulation group better on simulator
– No difference in clinical colonoscopy
Haycock at al, GIE. 2010; 71(2)298-307

20. Physical Models

21. Validation of Physical Simulator
• 21 experienced and 18 novices
• Showed construct validity
Plooy AM, et el. GIE. 2012;76(1):144-50.

24. Fundamentals of Endoscopic Surgery
• Currently in development by SAGES
• Didactic and skills-based
• VR Simulator
• 5 specific tasks
– Navigation, Tool manipulation, Mucosal
Inspection, Retroflexion, Loop Reduction

26. Back to Proficiency
• Goal of training in endoscopy
– Proficiency, not familiarity
• Simulation may help in early training
• Numerical milestones inadequate
• Need a tool to accurately assess proficiency

28. GAGES
• Global assessment of 60 novices and 79 experts
• 2 expert observers
• Results
– Construct validity
– Easy to use
– External validity (multiple sites)
• May contribute to the definition of technical
proficiency in basic endoscopy
Vassiliou et al. Surg Endosc. 2010; 24: 1834-41.

29. Importance of Proficiency
• Comprehensive care of GI Surgery patients
– Screening colonoscopy
– Follow up for colon cancer
– EGD for GERD
– Localize colon cancer
– EGD in bariatric patients

30. Intraoperative Endoscopy

31. Can endoscopy supplant UGI?
• 34 patients undergoing LPEHR
• EGD after dissection and after wrap
• No leaks, no wrap abnormalities
• All underwent UGI
– 1 column of barium
• EGD may supplant UGI in LPEHR

32. EGD during LRYGB
• Retrospective review of 2311 patients
• Intraop leak detected in 80 patients
– Suture line reinforced in 46
– 34 leaks only at high pressure
• Post op leaks detected in 4 patients
– 2 had intraop leaks which had been reinforced
Haddad A, et al. Obes Surg. 2012.

33. Pneumatic Testing during LRYGB
• 257 consecutive patients
• Roux limb clamped; insufflation with
endoscope
• Intraop air leaks in 25 patients
– 13 persistent air leaks (repaired and drained)
– 12 non-reproducible (drainage alone)
– 2 post op leaks—not at G-J anastamosis
Kligman MD. Surg Endosc. 2007; 21:1403-5.

34. Managing Post op Complications

36. Stents
• Meta-analysis of 7 studies
• 67 LRYGB patients with leaks
• 88% closure with stents
• 17% stent migration
Puli SR, et al. GIE. 2012; 75(2):287-93.

37. Clips

40. Endoscopic Suturing

41. Endoscopic Suturing

43. Dilating Strictures

44. Reducing Stoma Diameter
Thompson CC, et al. Surg Endosc. 2006; 20(11):1744-8.

45. Endoscopy after Fundoplication
• Tight fundoplication
– Early—wait
– Late—Balloon dilation
• Delayed gastric emptying
– ?Injury to vagus nerves
• Dilate pylorus, BOTOX injection
• Late dysphagia
– Dilate fundoplication

46. PEG Proficiency
• 160,000-200,000 PEGs performed annually in
US
• Morbidity in 9%
• Major complications in 1-3% of cases
• Mortality in 0.5%

48. Avoiding PEG Complications
• Does endoscopic experience matter?
• Does it matter who performs PEG?
• Are there techniques to reduce complications?

49. Endoscopic Innovations in Surgery
• NOTES
• TIF
• BARRX
• Bariatrics
• Resections
• Closure of Perforations
• POEM

50. TIF

51. TIF

52. Before After

53. TIF Data
• 100 consecutive reflux patients in 10 centers
• GERD-HRQL normalized in 73%
• 80% off PPIs at 6 months
• Significant reductions in reflux and
regurgitation scores
• No pH data
Bell at al. J Am Coll Surg. Aug 2012.

54. BARRX

59. RFA
• 90% eradication of low-grade dysplasia
• 80% eradication of high-grade dysplasia
• Ablation group
– 3% disease progression
– No invasive esophageal cancer

60. Endoscopy in Bariatrics

62. Gastrojejunal Barrier

64. Full thickness resection

65. Over the scope clips for GI perforation

69. POEM

73. Long-Term Outcomes
• 18 cases over 1 year
• 1 full-thickness perforation
• All 18 with dysphagia relief
• 2 patients with non-cardiac chest pain
• 50% with reflux at 6 mos on pH probe
– 6 patients complained of pyrosis
Swanstrom LL, et al. Ann Surg. Oct 2012.

74. Summary
• Surgeons perform endoscopy well
• Endoscopic training should focus on
proficiency
• Proficient endoscopists provide
comprehensive care to GI surgical patients
• Many surgical innovations have endoscopic
platform
• Endoscopy will be integral in GI surgery