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.

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

7. 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

8. Parts of Endoscope

10. Complete Endoscope Assembly

13. Types of endoscopy
Diagnostic
Therapeutic

14. Upper GI Small bowel
Therapeutic
Bilio-pancreatic Lower GI

15. 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

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

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

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

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

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

24. 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.

25. 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)

26. 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.

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

29. 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

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

31. • 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.

32. • 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

33. • 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)

34. 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

35. Types of dilators:
1. Guide-wire type
2. Balloon type
3. 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

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

37. 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)

38. 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.

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

41. Silicone stent:
• Removable
• Used for benign
strictures

42. 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

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

45. 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

46. Induces severe fibrosis at GE junction difficult for
myotomy later

47. Endoluminal treatment of GERD:
• Recently introduced in USA.
• Still under process of approval by FDA
1) 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

48. 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.

49. 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.

51. 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%.

52. 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:

53. Choledocholithiasis
Sphincter of oddi
dysfunction
Acute cholangitis
Acute gall stone
pancreatitis
Endoprosthesis
insertion

54. 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

57. 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

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

59. 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

60. 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

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

62. • 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.

63. Endoscopy for lower GI tract
1) Flexible sigmoidoscopy
2) 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

64. 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

65. • 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

66. • 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

67. 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.

68. 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.)

69. 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)

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

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

73. ADVANTAGES:
• No wound infection
• No incision hernia
• No post op adhesions

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

75. Thanking you
Thanking you
Thanking you