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Flexible endoscopy a surgeon's perspective

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A grand rounds presentation on flexible endoscopy for surgeons.

Publié dans : Santé, Santé & Médecine, Business

Flexible endoscopy a surgeon's perspective

  1. 1. Flexible Endoscopy: The Surgical Perspective Jonathan Pearl, MD
  2. 2. History of Surgical Endoscopy
  3. 3. Kelly, 1895 Hirschowitz, 1957
  4. 4. McCune, 1968 Shinya, 1968
  5. 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. 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. 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. 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. 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. 10. Navy Data • 566 colonoscopies by colorectal and general surgeons • 97% cecal intubation • 27% adenoma detection • No perforation • No post-polypectomy bleed
  11. 11. Training Requirements • RRC Requirements increased in 2009 – 50 colonoscopies – 35 EGDs • University of Maryland residents – 50-55 colonoscopies – 50 EGDs, including PEG
  12. 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. 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. 14. Are numbers important? • Want proficiency, not familiarity • Pushback from GI • Difficulty obtaining privileges
  15. 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. 16. Postgraduate Fellowship • 3 programs with focus on endoscopy – Louisville – Miami – Case Western • 100-200 colonoscopy • 200-300 EGD • 150-200 ERCP
  17. 17. How about simulation?
  18. 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. 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. 20. Physical Models
  21. 21. Validation of Physical Simulator • 21 experienced and 18 novices • Showed construct validity Plooy AM, et el. GIE. 2012;76(1):144-50.
  22. 22. 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
  23. 23. 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
  24. 24. 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.
  25. 25. 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
  26. 26. Intraoperative Endoscopy
  27. 27. 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
  28. 28. 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.
  29. 29. 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.
  30. 30. Managing Post op Complications
  31. 31. 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.
  32. 32. Clips
  33. 33. Endoscopic Suturing
  34. 34. Endoscopic Suturing
  35. 35. Dilating Strictures
  36. 36. Reducing Stoma Diameter Thompson CC, et al. Surg Endosc. 2006; 20(11):1744-8.
  37. 37. 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
  38. 38. 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%
  39. 39. Avoiding PEG Complications • Does endoscopic experience matter? • Does it matter who performs PEG? • Are there techniques to reduce complications?
  40. 40. Endoscopic Innovations in Surgery • NOTES • TIF • BARRX • Bariatrics • Resections • Closure of Perforations • POEM
  41. 41. TIF
  42. 42. TIF
  43. 43. Before After
  44. 44. 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.
  45. 45. BARRX
  46. 46. RFA • 90% eradication of low-grade dysplasia • 80% eradication of high-grade dysplasia • Ablation group – 3% disease progression – No invasive esophageal cancer
  47. 47. Endoscopy in Bariatrics
  48. 48. Gastrojejunal Barrier
  49. 49. Full thickness resection
  50. 50. Over the scope clips for GI perforation
  51. 51. POEM
  52. 52. 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.
  53. 53. 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

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