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Endoscopy for the General Surgeon
Advances in Surgery 42 (2008) 277–297
ADVANCES IN SURGERY Endoscopy for the General Surgeon Brian R. Davis, MD, Gary C. Vitale, MD* Department of Surgery, University of Louisville School of Medicine, Louisville, KY 40292, USA
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ndoscopy plays an integral role in the diagnosis and treatment of complex pathology and is emerging as the treatment of choice for many diseases. There is an explosion of interest in endoscopy with its provision of less invasive therapeutics through natural orifices. Surgeons need to be imaginative and take the forefront in exploring the therapeutic potential of endoscopy in their practices with the emergence of natural orifice transluminal endoscopic surgery (NOTES). There is a resurgence of training in this field, and the future is full of potential. ENDOSCOPIC TREATMENT OF GASTROESOPHAGEAL REFLUX DISEASE Gastroesophageal reflux disease (GERD) places a high burden on the health care system and is a common and frequently underdiagnosed condition. Up to 40% of Americans have reflux once a month, 14% experience it once a week, and 7% experience reflux daily [1]. Endoscopic modalities for treatment have been developed to address the high cost of pharmacologic and surgical treatment of this disease. Current surgical procedures are not perfect, with up to 28% of patients requiring some form of drug therapy at 5 years of follow-up after Nissen fundoplication [2]. Endoluminal therapies can be divided into three categories treating the gastroesophageal junction reflux barrier through (1) endoscopic suturing/stapling, (2) radiofrequency treatment, and (3) injectable prostheses. The NDO Plicator The endosurgical NDO Full-Thickness Plicator (NDO Surgical Inc., Mansfield, Massachusetts) restores the antireflux barrier with a single plication of the cardia. This plication consists of a pre-tied implant that secures a full-thickness serosa-to-serosa union. The procedure uses a specialized endoscope with a tissue retractor that engages the gastric wall mucosa 1 cm distal to the Z-line. The arms of the endoscope are closed around the retracted tissue, and a single *Corresponding author. E-mail address: [email protected] (G.C. Vitale). 0065-3411/08/$ – see front matter doi:10.1016/j.yasu.2008.04.007
ª 2008 Elsevier Inc. All rights reserved.
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pre-tied 2/0 polypropylene suture is fired, creating a placation in the gastric cardia (Fig. 1). This suture is placed over two bolsters, and two titanium retention bridges keep it in place. Symptoms are improved by altering the angle of His, restoring the valvular mechanism of the gastroesophageal junction, and reducing the compliance of the cardia and fundus. A multicenter trial involving 68 patients demonstrated that 74% of patients were medication free and had a significant improvement in GERD-related quality-of-life scores and significantly decreased distal esophageal acid exposure 6 months after the NDO Plicator procedure. Pleskow and colleagues [3] performed a long-term multicenter follow-up study demonstrating that these improvements in heartburn-related quality of life were stable between 1 and 3 years of follow-up.
Fig. 1. NDO Surgical, Inc. Plicator. (A) Endoscopic Plicator device. (B) Stages of the plication procedure. (1) Visualization of the cardia. (2) Grasping the cardia. (3) Closing the plication jaws on the cardia. (4) Pretied pledgeted suture creates the plication. (5) Results after plication has been finished. (From NDO Surgical, Mansfield, Massachusetts; with permission.)
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Stretta procedure The Stretta (Curon Medical, Palo Alto, California) procedure uses the delivery of temperature-controlled radiofrequency energy to the muscle layer of the gastroesophageal junction. This procedure improves the objective and subjective parameters of GERD by creating a controllable degree of tissue contraction and compliance reduction. This procedure decreases transient lower esophageal sphincter relaxations by causing nerve ablation and collagen deposition that thickens the gastroesophageal junction. The Stretta catheter consists of a soft tip followed by a balloon with four needle electrodes that deliver radiofrequency energy. The treatment consists of four applications, each lasting 90 seconds, extending from 1 cm above the Z-line to .5 cm below the Z line. Using a pull-back technique, two additional levels of application are done in the cardia (Fig. 2). This technique should not be used in patients who have Barrett’s esophagitis, subnormal lower esophageal sphincter pressures, or significant hiatal hernias (> 2 cm). A multicenter prospective trial by Triadafilopoulos [4] involving 118 patients demonstrated that at 12 months’ follow-up 69% of patients had improvements
Fig. 2. Stretta procedure. (A) Lower esophageal sphincter before procedure. (B) Lower esophageal sphincter after radiofrequency treatment. (C) Stretta endoscopic treatment catheter (Curon Medical, Sunnyvale, CA).
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in both heartburn and GERD-related quality-of-life scores that were equal to or better than the improvements seen on baseline drug therapy. At baseline 88.1% of these patients used proton-pump inhibitor therapy; after this procedure, only 30% used drug therapy at 12 months. In a prospective trial, Richards and colleagues [5] at Vanderbilt compared the Stretta procedure with laparoscopic fundoplication. They found that 51% of patients treated with the Stretta procedure no longer required medication, and 31% had reduced their medication dose significantly, whereas 97% of patients treated with fundoplication had stopped using medication. The study with the longest follow-up evaluation (3 years) was by Lufti and colleagues [6], who demonstrated that 65% of 77 patients were not taking proton-pump inhibitors at 6 months, but this proportion fell to 43% at 3 years. The efficacy at 3 years was counted as 64% if the group included those not taking proton-pump inhibitors and those taking half their original dose of this medication, making the overall response to this treatment significant. When compared with the risks of surgery, the Stretta treatment seems to be an effective alternative to Nissen fundoplication. Gatekeeper reflux repair system The Gatekeeper reflux repair system (Medtronic Inc, Minneapolis, Minnesota) uses a radiopaque hydrogel prosthesis that is delivered endoscopically into the submucosa at the lower esophageal sphincter. A 16-mm overtube is passed over a wire after initial endoscopy. Suction then is applied to catch mucosa in a shelf, and after needle injection of saline into the mucosa. the dry implant is placed into the submucosa. Correct placement is checked with a miniprobe endoscopic ultrasound. Three hydrogels are placed while the patient is under conscious sedation. A multicenter prospective trial by Fockens and colleagues [7] involving 67 patients demonstrated a 75% improvement in heartburn-related quality-of-life scores at 6 months. These patients also demonstrated a statistically significant decrease in distal esophageal exposure time (from 9.1% to 6.1%) and an increase in lower esophageal sphincter pressure (from 8.8 to 13.8 mm Hg). EndoCinch suturing system The Bard EndoCinch 2 Suturing System (Bard, Inc., Cranston, Rhode Island) can be described as an endoscopic sewing machine, which requires two endoscopes for repeated intubations to complete the plications. A suturing capsule uses suction to capture tissue 1 to 2 cm below the Z-line. Once the tissue is captured, the handle is advanced, passing a suture through the tissue. This step is repeated a second time approximately 1 cm adjacent to the first stitch. Through the use of the second endoscope, the two suture lines are secured with an anchoring device by apposing the tissue together, thus creating a plication. These pleats reduce compliance and functionally narrow the gastroesophageal junction (Fig. 3). A large, prospective, multicenter trial of this procedure demonstrated that 62% of patients at the 3- and 6-month follow-up were taking less than four doses of medication per month. Significant improvements also were noted in
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Fig. 3. Endoscopic appearance using the Bard EndoCinch. (A) Appearance of lower esophageal sphincter before procedure. (B) Retroflexed view of sphincter before procedure. (C) Appearance of lower esophageal sphincter after procedure. (D) Retroflexed view after procedure. (From Bard, Inc., Cranston, Rhode Island; with permission.)
the heartburn severity score, the heartburn frequency score, and the regurgitation score [8]. Chadalavada and colleagues [9] performed a prospective trial demonstrating that the 32% of the group treated with the EndoCinch resumed drug therapy, whereas 13% of the group treated with laparoscopic fundoplication group resumed drug therapy. Enteryx The Enteryx System (Boston Scientific, Natick, Massachusetts) involves injecting a biocompatible co-polymer into the lower esophageal sphincter to alleviate GERD symptoms. The co-polymer is placed endoscopically in an intramuscular location under fluoroscopic guidance in a circumferential distribution at the
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lower esophageal sphincter. Injections are made 1 to 3 mm proximal to the Z-line in four quadrants (Fig. 4). The presence of this substance elicits an acute inflammatory reaction that creates a fibrous capsule that results in decreased lower esophageal sphincter muscle distensibility, thus altering the compliance of the gastroesophageal junction. After treatment, normal physiologic function of the esophagus resumes, allowing lower esophageal sphincter relaxation upon the ingestion of food. Long-term follow-up has shown that the Enteryx prosthesis is stable over time, and a prospective multicenter trial involving 85 patients has demonstrated an 80.3% response rate (defined as complete independence from medication or up to a 50% reduction in medication dosage at 1 year follow-up) [10]. In September 2005 the Food and Drug Administration recalled Enteryx because of adverse reports of injection into the mediastinum, pleural space, and aorta. It is possible that some improved variation of this technique may become feasible. Although most of these studies on endoscopic therapies exclude patients who have severe reflux, they provide evidence that these procedures are effective and safe for patients wishing to forego drug therapy for reflux disease. ENDOSCOPIC TREATMENT OF GASTROINTESTINAL BLEEDING Endoscopy is integral in the management of upper gastrointestinal bleeding and is able to identify the source of hemorrhage in more than 90% of lesions. Endoscopy reduces the incidence of emergent operations and the overall mortality from acute upper gastrointestinal bleeding. Treatments range from
Fig. 4. Cross-sectional view of cardia showing the Enteryx implant. (From Mason RJ, Hughes M, Lehman GA, et al. Endoscopic augmentation of the cardia with a biocompatible injectable polymer (Enteryx) in a porcine model. Mason RJ, Hughes M, Lehman GA, et al. Surg Endosc 2002;16:388.)
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banding esophageal varices to the use of clips and heater probes to address acute bleeding. Endoscopic pre-emptive therapy for esophageal varices is justified, given the high mortality rate (50%) from upper gastrointestinal bleeding at 1 year in patients who have advanced cirrhosis. Traditional sclerotherapy is giving way to endoscopic rubberband ligation of esophageal varices. Equal rates of hemorrhage control have been shown with banding and sclerotherapy, and banding has a lower incidence of stricture formation [11]. The banding device has multiple preloaded rubber bands that are released by a trigger after the mucosa has been sucked into the scope, thereby strangling the superficial venous vessels that thrombose and slough (Fig. 5). With band ligation, up to 75% of varices recur in 6 months. Repeat treatment is necessary. Peptic ulcers also commonly cause acute upper gastrointestinal bleeding. Ulcer bleeding can be treated by injection therapy in which dilute epinephrine (1:10,000) can be injected into the ulcer bed. Metallic clips can be applied with a special endoscopic applicator when bleeding vessels can be visualized directly. Contraindications to using clips include fibrotic ulcers, diffuse bleeding, large bleeding ulcers, and bleeding gastric cancers. Heater probes also have been developed that use heat and pressure to squeeze and seal the vessel, creating mucosal and submucosal coagulation and avoiding a full-thickness burn. After pressure occlusion, the probe applies multiple sequential pulses of 30 to 120 J to cause coagulation and thrombosis. A bipolar circumactive probe allows more precise control of the bleeding, provides irrigation of the bleeding point, and applies multiple short energy pulses given in rapid succession [12]. These short pulses cause less damage than monopolar cautery or yttrium aluminum garnet (YAG) laser therapy. The neodymium-doped (Nd):YAG laser and argon-beam coagulator have been useful for the treatment of bleeding angiodysplasias in the upper gastrointestinal tract.
Fig. 5. Esophageal varix band ligation with a multiband device. (From de Franchis R, Primignani M. Endoscopic treatments for portal hypertension. Semin Liver Dis 1999;19:443.)
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Combinations of these technologies have demonstrated no benefit in using banding and sclerotherapy together but demonstrated marked resolution of varices when banding was used with epinephrine injections and argon-beam coagulation for acute bleeding [13]. In peptic ulcer therapy, the combination of injection therapy with the heater probe has shown no benefit, but the use of injection therapy with argon-beam coagulation has been shown to be effective, especially when there is active bleeding or when an exposed vessel present [14]. Capsule endoscopy for gastrointestinal bleeding The reference standard for detection of occult gastrointestinal bleeding in inflammatory bowel disease has been intraoperative endoscopy. Before the use of endoscopes, the detection rate for occult bleeding lesions at laparotomy was as low as 30%, but the rate of detection has increased to 90% with the use of modern equipment. The least invasive challenge to the reference standard is capsule endoscopy. The Capsule Endoscope (Given Imaging, Yoqneam, Israel) contains a miniature metal oxide silicone chip video camera with four light-emitting diode illumination sources (Fig. 6). The image field of view is 140 , the magnification is
Fig. 6. Capsule endoscope. (From Given Imaging Ltd., Duluth, Georgia; with permission.)
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1:8, the depth of view is 1 to 30 mm, and the minimum size of lesion detection is 0.1 mm. A short focal length lens with a narrow aperture is used to increase the depth of the field. The capsule is swallowed and propelled by intestinal peristalsis. Images are obtained as the optical window of the capsule sweeps past the gut wall without requiring air inflation of the lumen. Video images are transmitted using radio telemetry (432 MHz) at a rate of two frames per second and are transmitted to eight sensors secured to the body. More than 50,000 images captured over an 8-hour period are stored in a digital recorder worn around the patient’s waist. The position of the capsule within the abdomen can be calculated by the strength of the signal relative to each sensor with an accuracy of up to 3 cm in the localization of visualized lesions. Capsule endoscopy has been compared with small bowel radiology. Enteroclysis has a diagnostic yield of 90% in patients who have small bowel tumors, but rate drops to 10% to 20% in detecting small bowel bleeding sources. Costamagna and colleagues [15] compared barium follow-through findings with capsule endoscopy for occult bleeding and inflammatory bowel disease indications in 20 patients. The capsule was considered to be diagnostic in 45%, compared with 27% in barium studies. Liangpunsakul and colleagues [16] used capsule endoscopy to assess 40 patients who had negative standard upper and lower endoscopy and normal radiologic studies. Abnormal findings were discovered in 83% of these patients; 63% had angiodysplasias, ulcers, or submucosal lesions. Capsule endoscopy provides visualization of these lesions that often are difficult to detect even when standard endoscopy can intubate the jejunum. Flexible endoscopes of sufficient length to intubate the proximal jejunum (push endoscopy) have been developed, and other scopes are carried into the distal small bowel by the action of peristalsis (Sonde endoscopy). Several prospective trials have demonstrated that capsule endoscopy has a better diagnostic yield than push endoscopy or Sonde enteroscopy in the detection of occult gastrointestinal bleeding. Mylonaki and colleagues [17] examined 50 patients prospectively and found that capsule endoscopy detected a small bowel source of bleeding in 68% of patients, whereas push endoscopy identified a source in only 32% of these patients. This study did note that the diagnostic yields of capsule and push enteroscopy are nearly identical when the jejunum is thought to be the source of bleeding. Prospective studies using capsule endoscopy as a first-line test in diagnosing the source of occult bleeding noted a decreased yield, with only 42% of studies being of diagnostic value, compared with its use in combination with standard endoscopy. Studies comparing intraoperative endoscopy with capsule endoscopy are underway. ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY Advances in endoscopic retrograde cholangiopancreatography (ERCP) have allowed minimally invasive approaches to interventions that normally carry a high morbidity and mortality in elderly patients and provide alternatives to
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pancreatic and biliary reconstructions that carry high risks of complications in patients who have chronic pancreatitis and gastrointestinal cancers. Endoscopic management of pancreatic pseudocysts ERCP has played a revolutionary role in managing the complications of pancreatitis. ERCP plays a beneficial role in defining the ductal anatomy in up to 80% of all pancreatic pseudocysts. Pseudocysts with favorable anatomy then can be drained endoscopically through the stomach or duodenum or through a transpapillary approach. Transenteric drainage routes are best suited for cysts that have well-developed walls that demonstrate indentation of the gastrointestinal tract or with demonstrated enteric adherence as determined by endoscopic ultrasound. Cyst-enteric drainage is optimal for pseudocysts with walls less than 1 cm thick when the ERCP demonstrates pancreatic ductal disruption or stricture. The transpapillary route should be considered when a stent can be placed directly through the duct into the pseudocyst after pancreatography demonstrates a communication between the pancreatic duct and the pseudocyst cavity [18]. Contraindications to the endoscopic procedure include ongoing pancreatic necrosis or suspicion of malignancy. In a series of 49 patients, De Palma and colleagues [19] demonstrated effective transmural drainage in 27 of 30 patients (90%) and effective transpapillary drainage 16 of 19 patients (84.2%). The University of Louisville experience documents a series of 59 patients with a total of 61 pseudocysts that were drained effectively endoscopically. This series included 30 cystgastrostomies, 11 cyst duodenostomies, and 24 transpapillary drainage procedures (Fig. 7). Complete resolution of the pseudocyst was achieved in 85% of patients. The Louisville experience also reports 34 patients who underwent endoscopic drainage for pancreatic abscesses associated with necrotizing pancreatitis. Abscesses were drained by
Fig. 7. Transgastric pancreatic pseudocyst drainage.
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cystgastrostomies [15], cystduodenostomies [4], and transpapillary drainage [16]. Endoscopic drainage of the pancreatic abscess was achieved in 80% of these patients [20]. These results prove that endoscopic drainage offers an effective therapeutic option with minimal morbidity and mortality. Endoscopic stenting for chronic pancreatitis The goals of endoscopic pancreatic duct stenting in chronic pancreatitis include pain control to allow nutritional rehabilitation and to resolve drug dependency issues and resolution of recurrent pancreatitis caused by ductal obstruction. The chronic pancreatitis pain syndrome is thought to arise from high intraductal pressures, perineural fibrosis, and a pancreatic compartment syndrome in which pancreatic scarring increases intraparenchymal pressure, thus decreasing blood flow. Pancreatic duct stenting for patients who have pancreatic duct strictures and pancreas divisum is believed to relieve high duct pressures and pancreas compartment syndrome. Farnbacher and colleagues [21] studied a series of 96 patients who had stenosis in the pancreatic duct treated by repeat stenting for a follow-up of 15 months. He reported a response rate of 82% with complete or partial relief of pain at 10 months and a response rate of 59% at 3 years. This study demonstrates that select patients who are early responders to pancreatic stent drainage are likely to benefit over the long term and that stent removal after stricture dilation may be associated with continued long-term pain relief. Coleman and colleagues [22] demonstrated that, in 34 patients who had pancreas divisum, stenting of the minor ampulla provided relief for 78% of those who had acute recurrent pancreatitis and for 60% of those who had chronic pancreatitis. The University of Louisville experience with pancreatic duct stenting for chronic pancreatitis demonstrates a response rate of 68%, with patients experiencing either no recurrence of pancreatitis or a less severe recurrence. Forty-seven percent of the patients reported a decrease in the use of pain medication, and 17% reported a significant weight gain after this procedure. This experience has demonstrated that the use of pancreatic duct stents reduces the intensity of chronic pain, the frequency of relapse, and the duration of pancreatitis in patients experiencing chronic pancreatitis (Fig. 8) [23]. Endoscopic therapy combined with thoracic splanchnicectomy has shown a unique efficacy in treating chronic pancreatitis. The Louisville experience with this
Fig. 8. (A) Pancreatic duct stricture. (B) Stricture with stent in the pancreatic and bile ducts.
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technique demonstrates a success rate of 68% (in 54 patients) in decreasing the intensity of pain and hospital admissions 1 year after surgery [24]. Endoscopic stenting for biliary strictures Endoscopic stenting after diagnostic ERCP also is a valuable tool in the management of biliary tract strictures. Strictures may be benign, arising from trauma (iatrogenic or accidental), chronic pancreatitis, sclerosing cholangitis, or stone disease (Mirizzi’s syndrome), or malignant, arising from cholangiocarcinoma, pancreatic carcinoma, or ampullary carcinoma. Benign strictures often result from iatrogenic injuries during cholecystectomy [25]. Biliary fistulae may occur from a cystic duct leak or an accessory hepatic duct as well as from a major duct injury. Bile duct stenting can decompress the biliary tract, allowing spontaneous closure of the leak. ERCP with stenting also plays a role in managing major hepatic duct and common bile duct injuries, draining the biliary tree before formal reconstruction. The University of Louisville experience over a 5-year period documented successful endoscopic management of 65 of 67 benign bile duct strictures of all origins, with resolution of symptoms and normal liver function tests after the procedure [26]. Long-term follow-up demonstrates a recurrence rate of 17%, which is similar to the long-term recurrence rates for surgical repair [27]. Long-term follow-up is necessary with both endoscopic and surgical management of these injuries to detect early recurrent stricture (Fig. 9). Malignant biliary strictures also are managed endoscopically for palliation. The University of Louisville experience over a 5-year period examined a series of 132 patients who had malignant biliary strictures managed with endoscopic therapy alone (69%), endoscopic and radiation therapy (11%), or surgical approaches (24%) [24]. The average survival in the surgical group was 16.5 months, compared with a 19 months in the endoscopic group. The total lifetime cost was $60,000 for surgery and $24,000 for endoscopic treatment [28]. For inoperable cancer, the preference has been to use metallic stents that have high patency rates and do not require multiple patient visits for stent changes (Fig. 10). The authors’ experience demonstrates that 31 of 34 metallic
Fig. 9. (A) Bile duct stricture after cholecystectomy. (B) Stenting of iatrogenic bile duct stricture.
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Fig. 10. Metallic stent in the common bile duct for a malignant stricture.
stents placed over a 4-year period remained patent until the patient’s death [29]. Recently, biliary stents have been placed temporarily while the patient undergoes chemoradiation treatment with the intent to resect the tumor in patients who have a good response. ENDOSCOPIC ENTERIC STENTING FOR MALIGNANCY Endoscopic therapy has been a mainstay for the palliation of esophageal cancer for a number of years, and recent trends in stenting demonstrate the benefits of duodenal stenting in unresectable pancreatic cancer and of colonic stenting of obstructive cancers for palliation or as a bridge to surgery. The largest retrospective study of palliative duodenal stenting, involving 176 patients, demonstrated a success rate of 98% with a complication rate of 14%. Eighty-four percent of these patients were able to resume oral intake for a median of 146 days [30]. Surgeons from Spain have reported a prospective study comparing duodenal stenting with gastrojejunostomy for the palliation of pancreatic cancer. They compared 24 cases of stenting with 17 cases of surgery. The length of hospital stay was 7.1 days for stenting versus 11.5 days for the surgery group, and the median survival was 20 weeks for stenting versus 21.6 weeks for the surgical group. Thirty-day mortality was 16.6% for the stented group and 29.4% for the surgery group, with complications of 4% and 17.6%, respectively. Efficient gastric emptying was seen in 100% of the stented group with a time to food tolerance of 2.4 days, whereas in the surgical group the rate of efficient gastric emptying was 82.3% with a time to food tolerance of 5 days [31]. Thus, duodenal stenting reduces the morbidity and improves quality of life in the palliative treatment of pancreatic cancer.
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Several groups have reported on the use of colonic stents in malignant colonic obstruction as a bridge to surgery and as palliation. Controversy surrounding this procedure relates to the perceived increased risk of metastasis and further invasion of the cancer. Tilney and colleagues [32] performed a recent meta-analysis on colonic stenting demonstrating that the use of colonic stenting as a bridge to surgery did not affect survival adversely. In this analysis of 10 studies and 244 patients, treatment with stenting proved successful in 92.6% of cases. Stenting provided a lower mortality rate than emergency surgery (5.7% versus 12.1%) and fewer complications than emergency surgery. Stenting of the colon is a safe and effective procedure for palliation and is a good bridge to surgical therapy, allowing a one-stage surgical procedure with curative intent. Endoscopic mucosal resection Endoscopic mucosal resection was developed in Japan in the 1980s by Tada and colleagues [33] for the treatment of early gastric and esophageal cancer. The initial technique is similar to that of resecting colonic polyps with submucosal injection of saline and snaring of the lesion. This technique has been applied widely only in Japan, where the early detection of gastric and esophageal cancer is high, and the prevalence of nodal metastasis is low. Inoue and colleagues [34] in Japan modified this technique by performing resection with the plastic cap used in band ligation of esophageal varices. The oblique-cut Inoue cap has a circular rim at the tip to accommodate a snare-wire loop. The lesion is injected, and the target lesion is covered with the cap. The snare wire then advances to form a loop along the rim of the cap. Suction draws the mucosa into the cap, and the lesion is strangulated by closing the pre-looped snare wire (Fig. 11). Electrocautery excises the tissue, and the specimen in withdrawn inside the cap for pathologic examination. Variations on this technique include band ligation using a standard variceal banding device that is able to perform en bloc resections of lesions up to 1.5 cm in diameter. After ligation, a standard polypectomy is performed below the rubber band with snare electrocautery. The newest innovation demonstrates en bloc resection of large mucosal lesions using lift-and-cut techniques with insulation tip diathermic knives [35]. ENDOSCOPIC ABLATION OF BARRETT’S ESOPHAGUS Barrett’s esophagus is a condition associated with GERD in which the normal stratified squamous epithelium of the esophagus is replaced by columnar epithelium. Barrett’s esophagus is a premalignant condition with an estimated risk of 0.5% per year of developing adenocarcinoma of the esophagus. Many studies have hypothesized that this condition progresses from a low-grade dysplasia to high-grade dysplasia and eventually to adenocarcinoma. The standard therapy for high-grade dysplasia has been esophagectomy. Less invasive approaches traditionally have included serial endoscopy with biopsy until high-grade dysplasia is found. This approach usually detects cancer at a curative stage, but the high mortality and morbidity rates for esophagectomy have led
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Fig. 11. Endoscopic mucosal resection. (A) Island of Barrett esophagus in proximal esophagus. (B) Barrett’s lesion tissue suctioned into endoscopic cap. (C) Snare cautery of lesion inside endoscopic cap. (D) Esophagus mucosa after resection of Barrett’s lesion. Lesion has not recurred.
to the development of endoscopic ablative therapies to eliminate the presence of Barrett’s esophagus and high-grade dysplasia. Initial attempts at ablative therapy to treat high-grade dysplasia and early cancer were reported by Overholt and colleagues [36], who in 1993 developed photodynamic therapy. This therapy involves administration of a photosensitizing pharmacologic agent followed by exposure to endoscopically delivered laser light. Prospective studies of this technique by Overholt and colleagues demonstrated a 75% efficacy in eliminating high-grade dysplasia durable up to 18 months, with 13% of patients progressing to cancer. Complications of this therapy include photosensitivity (69%) and esophageal strictures (36%). The rate of esophageal stricture in this study increased with repeat applications of photodynamic therapy, which were required in more than half of the patients in this study. Complications with this procedure and the need for
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multiple applications led to further innovation in the endoscopic treatment of Barrett’s esophagus. Effective destruction of Barrett’s esophagus has been achieved with the BARRX Halo-360 system (BARRX Medical, Sunnyvale, California). This system consists of an endoscopic balloon catheter attached to a radiofrequency generator that delivers short bursts of energy that circumferentially ablate a 3-cm area of tissue (Fig. 12). Fleisher and colleagues [37] reported initial results of this procedure demonstrating a 41% cure rate and a 54% partial response rate with no evidence of stricture formation. Sharma and colleagues [38] demonstrated a 70% complete response rate to radiofrequency ablation therapy at 1 year in 70 patients. This protocol delivers 10 J/cm2 to the Barrett’s esophagus (applications lasting 1 second) for a single treatment followed by repeat serial endoscopy and biopsy at 1, 3, 6, and 12 months. Patients found to have residual Barrett’s esophagus at biopsy underwent a second application of this treatment 3 months after the initial therapy. There were no complications from the use of this procedure; thus its efficacy and safety in prophylactic treatment of Barrett’s esophagus have been demonstrated. TRANSANAL ENDOSCOPIC MICROSURGERY Local excision as described in earlier sections also has been used for selected rectal cancers. Lesions in the mid and lower rectum first were addressed with transanal endoscopic microsurgery by Buess in 1982 [39]. This technique was used initially for excision of benign adenomas and palliation of cancer.
Fig. 12. The BARRX Halo 360 ablation catheter in place in the esophagus to treat Barrett’s esophagus. (From BARRX Medical, Sunnyvale, California; with permission.)
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Currently, transanal endoscopic microsurgery is used with curative intent for T1 tumors and is used routinely for palliation of T2 and T3 tumors. Operations are performed with multiple instruments within an operating endoscope, performing tasks such as suturing as high as 20 cm into the rectum. Full-thickness excision is performed to the pericolic fat, and the excision is closed transversely with a running suture. Patients often are discharged home the day of surgery with only minor postoperative sphincter dysfunction. Maslekar and colleagues [40] studied 52 patients who underwent transanal endoscopic microsurgery excision of a rectal cancer. Forty-two of these patients had T1 tumors, 8 had T2 tumors, and 2 had T3 tumors. Follow-up at 40 months demonstrated that the overall local recurrence rate was 14% and involved only T2 and T3 cancers. This study demonstrated that transanal endoscopic microsurgery is a safe and effective treatment for early rectal cancers that can reduce the morbidity and mortality of standard operative resections. Endoscopic bariatric surgery As endoluminal endoscopic techniques have evolved, the applications for bariatric surgery have become apparent. Obesity is an increasing health problem affecting a large portion of the United States population. With the high complication rate of laparoscopic bariatric surgery (12%–15%) and the high incidence of gastrojejunostomy leaks (2%–5%), a demand has developed for a less invasive procedure that can be performed under conscious sedation. Current interventions are used mostly for preoperative weight loss and for the treatment of postoperative complications [41]. Surgeons have advocated a two-stage approach to bariatric surgery to reduce the anesthesia risks in superobese patients. Endoluminal therapies are being used as temporary adjuncts to preoperative weight loss. Several surgeons have used the BioEnterics Intragastric Balloon (Allergan, Irvine, California) as a bridge to weight loss and as primary therapy for weight loss. Mathus-Vliegen and Tytgat [42] presented a long-term outcome study with balloon treatment that demonstrated that 70% of patients lost 15% of their body weight after a 3-month balloon treatment. Although these patients did regain weight after balloon removal, their weight at 1-year follow-up remained 9.9% below their prestudy weight. This finding argues for the use of temporary endoluminal gastric partitioning as a bridge to more formal gastric bypass in the superobese. Late complications after bariatric surgical procedures can include staple-line disruptions, dilation of the gastric pouch or stoma, stomal stenosis, anastomotic stricture, and enteric fistulas. Endoluminal techniques have been used to address these complications. Thompson and colleagues [43] treated patients who had a dilated gastrojejunal anastomosis and significant weight regain with the EndoCinch suturing system (Bard, Covington, Georgia). Plications were placed at the rim of the anastomosis, thus reducing the gastrojejunal aperture. Six of eight patients treated with this endoluminal therapy demonstrated a weight loss of more than 10 pounds at 4 months. Sclerotherapy also has been
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used to reduce the size of the gastrojejunal stoma, and fibrin glue has been applied endoscopically to treat gastrocutaneous fistulae. Endoluminal interventions are being developed in animal models to serve as primary, stand-alone weight loss therapies. Hu and colleagues [44] created a 30-mL gastric pouch using endoscopic suturing. Swain and colleagues [45] have developed the butterfly endoluminal gastroplasty procedure that involves the creation of a small gastric pouch with a restrictive outlet that can be adjusted endoscopically at a later date. Developing technologies include stapling systems to create limited gastric pouches, endoscopically delivered electric gastric stimulators, intragastric volume reduction devices, and endoscopically deployed sleeves that divert food through the duodenum. Significant technical hurdles still must be overcome before these therapies become viable alternatives to the gastric bypass for the growing problem of morbid obesity. There is little doubt, however, that an endoscopic approach that refines these techniques for treating obesity soon will be developed successfully.
NATURAL ORIFICE TRANSLUMINAL ENDOSCOPIC SURGERY Endoscopic techniques that sample tissues and drain collections through the enteric lumen have evolved into NOTES. Transluminal endoscopic techniques have been used since 1993 to drain pancreatic pseudocysts and abscesses. Seifert and colleagues [46] described endoscopic pancreatic debridement with a dormia basket through the stomach wall, which included removal of a necrotic spleen. These innovations have included unpublished reports of transgastric endoscopic appendectomy in humans in India [47]. These developments have led to an explosion of scientific interest in NOTES that is being tested in animal models and in patients throughout the world. NOTES has evolved from an exploratory procedure to formal organ resection. Models for abdominal exploration began with Kalloo and colleagues [48] at Johns Hopkins who developed a model for peroral transgastric surgery in pigs that has been used for liver biopsy. This group has developed animal models for transgastric cholecystectomy, splenectomy, tubal ligation, and gastrojejunal anastomosis. Bergstrom and colleagues [49] and Park and colleagues [50] in London also have developed animal models using endoscopic ultrasound as a tool for procedures ranging from treating reflux with transgastric sutures placed into the crura to endoscopically creating a gastrojejunostomy and cholecystogastrostomy. Merrifield and colleagues [51] and Pai and colleagues [52] have taken the development of this surgery further, ranging from a transgastric hysterectomy model to a transcolonic cholecystectomy model. The future holds exciting advances for endoscopy as a primary treatment modality for many diseases. These advances occur as the diagnostic technology in screening for diseases improves. Further involvement of the surgeon in these treatments will require collaborative efforts with interventional gastroenterologists. This collaboration in innovation and development ultimately will lead to
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the best care for the patient, expanding the range of therapeutic options for those faced with a wide range of common diseases. Acknowledgment The authors thank Judy Slaughter for her editorial assistance with this article. References [1] Locke GR, Talley NJ, Fett SL, et al. Prevalence and clinical spectrum of gastroesophageal reflux: a population based study in Olmstead County, Minnesota. Gastroenterology 1997;112:1448–56. [2] Liu JY, Woloshin S, Laycock WS. Late outcomes after laparoscopic surgery for gastroesophageal reflux. Arch Surg 2002;137:397–401. [3] Pleskow D, Rothsten R, Kozarek R, et al. Endoscopic full-thickness plication for the treatment of GERD: long-term multicenter results. Surg Endosc 2007;21:439–44. [4] Triadafilopoulos G, DiBaise J, Nostrant T, et al. The Stretta procedure for the treatment of GERD: 6 and 12-month follow-up of the U.S. open label trial. Gastrointest Endosc 2002;55:149–56. [5] Richards WO, Houston HL, Torquati A, et al. Paradigm shift in the management of gastroesophageal reflux disease. Ann Surg 2003;237:638–49. [6] Lufti RE, Torquati A, Kaiser J, et al. Three year’s experience with the Stretta procedure: did it really make a difference? Surg Endosc 2005;19:289–95. [7] Fockens P, Bruno MJ, Gabbrielli A, et al. Endoscopic augmentation of the lower esophageal sphincter for the treatment of gastroesophageal reflux disease: multicenter study of the Gatekeeper Reflux Repair System. Endoscopy 2004;36:682–9. [8] Filipi C, Lehman G, Rothstein R, et al. Transoral flexible endoscopic suturing for treatment of GERD: a multicenter trial. Gastrointest Endosc 2001;53:416–22. [9] Chadalavada R, Lin E, Swafford V, et al. Comparative results of endoluminal gastroplasty and laparoscopic antireflux surgery for the treatment of GERD. Surg Endosc 2004;18: 261–5. [10] Johnson DA, Ganz R, Aisenberg J, et al. Endoscopic implantation of enteryx for treatment of GERD: 12-month results of a prospective, multicenter trial. Am J Gastroenterol 2003;98: 1921–30. [11] Seewals S, Seitze U, Thonke F, et al. Interventional endoscopic treatment of upper gastrointestinal bleeding—when, how, and how often. Langenbecks Arch Surg 2001;38:88–97. [12] Blocksom JM, Tokioka S, Sugawa C. Current therapy for nonvariceal upper gastrointestinal bleeding. Surg Endosc 2004;18:186–92. [13] Cipoletta L, Bianco MA, Rotondano G, et al. Argon plasma coagulation prevents variceal recurrence after band ligation of esophageal varices: preliminary results of a prospective randomized trial. Gastrointest Endosc 2002;56:600–3. [14] Chau CH, Siu WT, Low BK, et al. Randomized controlled trial comparing epinephrine injection plus heat probe coagulation versus epinephrine injection plus argon plasma coagulation for bleeding peptic ulcer. Gastrointest Endosc 2003;57:455–61. [15] Costamagna G, Shah SK, Riccioni ME, et al. A prospective trial comparing small bowel radiographs and video capsule endoscopy for suspected small bowel disease. Gastroenterology 2002;123:999–1005. [16] Liangpunsakul S, Chadalawada V, Rex DK, et al. Wireless capsule endoscopy detects small bowel ulcers in patients with normal results from state of the art enteroclysis. Am J Gastroenterol 2003;98:1295–8. [17] Mylonaki M, Fritscher-Ravens A, Swain P. Wireless capsule endoscopy: a comparison with push enteroscopy in patients with gastroscopy and colonoscopy negative gastrointestinal bleeding. Gut 2003;52:1122–6. [18] Vitale GC, Lawhon JC, Larson GM, et al. Endoscopic drainage of the pancreatic pseudocyst. Surgery 1999;126:616–23.
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[19] De Palma G, Galloro G, Puzziello A, et al. Endoscopic drainage of pancreatic pseudocysts: a long-term follow up study of 49 patients. Hepatogastroenterology 2002;49:1113–5. [20] Vitale GC, Davis BR, Vitale M, et al. Natural orifice translumenal endoscopic drainage for pancreatic abscesses. Surg Endosc (in press). [21] Farnbacher MJ, Radespiel-Troger M, Konig MD, et al. Pancreatic endoprostheses in chronic pancreatitis: criteria to predict stent occlusion. Gastrointest Endosc 2006;63(1):60–6. [22] Coleman SD, Eisen GM, Troughton AB, et al. Endoscopic treatment in pancreas divisum. Am J Gastroenterol 1994;89(8):1152–5. [23] Vitale GC, Cothron K, Vitale EA, et al. Role of pancreatic duct stenting in the treatment of chronic pancreatitis. Surg Endosc 2004;18(10):1431–4. [24] Davis BR, Vitale M, Lecompte M, et al. An objective study of pain relief in chronic pancreatitis from bilateral thoracoscopic splanchnicectomy. Am Surg 2008;74(6):510–4. [25] Vitale GC, Reed DN, Nguyen CT, et al. Endoscopic treatment of distal bile duct strictures from chronic pancreatitis. Surg Endosc 1999;14:227–31. [26] Vitale GC, George M, McIntyre K, et al. Endoscopic management of benign and malignant biliary strictures. Am J Surg 1996;171:553–7. [27] Davids PH, Rauws EA, Coene PP, et al. Endoscopic stenting for post-operative biliary strictures. Gastrointest Endosc 1992;38:12–8. [28] Martin RG, Vitale GC, Reed DN, et al. Cost comparison of endoscopic and stenting vs surgical treatment for unresectable cholangiocarcinoma. Surg Endosc 2000;16:667–70. [29] Vitale GC, Larson GM, George M, et al. Management of malignant biliary strictures with self expanding metallic stent. Surg Endosc 1996;10:970–3. [30] Telford JJ, Carr-Locke DL, Baron TH, et al. Palliation of patients with malignant gastric outlet obstruction with the enteral Wallstent: outcomes from a multicenter study. Gastrointest Endosc 2004;60:916–20. [31] Espinel J, Sanz O, Vivas S, et al. Malignant gastrointestinal obstruction: endoscopic stenting versus surgical palliation. Surg Endosc 2006;20:1083–7. [32] Tilney HS, Lovegrove RE, Purkayasatha S, et al. Comparison of colonic stenting and open surgery for malignant large bowel obstruction. Surg Endosc 2007;21:225–33. [33] Tada M, Shimada M, Murakami F, et al. Development of the strip-off biopsy. Gastrointest Endosc 1984;26:833–9. [34] Inoue H, Takeshita K, Hori H, et al. Endoscopic mucosectomy for early cancer using a prelooped plastic cap. Gastrointest Endosc 1984;40:263–4. [35] Soetikno RM, Gotoda T, Yukihiro N, et al. Endoscopic mucosal resection. Gastrointest Endosc 2003;57:567–78. [36] Overholt BF, Lightdale CJ, Wang KK, et al. Photodynamic therapy with porfimer sodium for ablation of high grade dysplasia in Barrett’s esophagus: international partially blinded, randomized phase III trial. Gastrointest Endosc 2005;62(4):488–98. [37] Fleisher DF, Sharma VK, Reymunde A, et al. A prospective multicenter evaluation of ablation of nondysplastic Barrett’s esophagus using the BARRX Bipolar Balloon Device: the ablation of intestinal metaplasia ii trial: (AIM-II). Gastroenterology 2005;128:A236. [38] Sharma VK, Wang KK, Overholt BF, et al. Balloon-based, circumferential, endoscopic radiofrequency ablation of Barrett’s esophagus: 1-year follow-up of 100 patients. Gastrointest Endosc 2007;65:185–95. [39] Buess G, Mentges B, Manncke K, et al. Technique and results of transanal endoscopic microsurgery in early rectal cancer. Am J Surg 1992;163:63–9. [40] Maslekar S, Pillinger SH, Monson JR. Transanal endoscopic microsurgery for carcinoma of the rectum. Surg Endosc 2007;21:97–102. [41] Schauer P, Chand B, Brehauer S. New applications for endoscopy: the emerging field of endoluminal and transgastric bariatric surgery. Surg Endosc 2007;21:347–56. [42] Mathus-Vleigen EM, Tytgat GN. Intragastric balloon for treatment-resistant obesity: safety, tolerance, and efficacy of 1-year balloon treatment followed by a 1-year balloon-free follow up. Gastrointest Endosc 2005;61:19–27.
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[43] Thompson CC, Slattery J, Bunda ME, et al. Per-oral endoscopic reduction of dilated gastrojejunal anastomosis following Roux-en-Y gastric bypass a possible new option for patients with weight regain. Surg Endosc 2006;20:1744–8. [44] Hu B, Chung SC, Kawashima K, et al. Transoral obesity surgery: endoluminal gastroplasty with an endoscopic suturing device. Endoscopy 2005;37:411–5. [45] Swain CP, Park PO, Savides T, et al. In vivo evaluation of the butterfly endoluminal gastroplasty procedure for obesity. Gastrointest Endosc 2003;57:AB83. [46] Seifert H, Wehrmann T, Schmitt T, et al. Retroperitoneal endoscopic debridement for infected peripancreatic necrosis. Lancet 2000;356:653–5. [47] Hochberger J, Wolfram L. Transgastric surgery in the abdomen: the dawn of a new era? Gastrointest Endosc 2005;62:293–5. [48] Kalloo AN, Singh VK, Jagannath SB, et al. Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity. Gastrointest Endosc 2004;60:114–7. [49] Bergstrom M, Keiichi I, Swain P, et al. Transgastric anastomosis by using flexible endoscopy in a porcine model. Gastrointest Endosc 2006;63:307–12. [50] Park P, Bergstrom M, Keiichi I, et al. Experimental studies of transgastric gallbladder surgery: cholecystecomy and cholecystogastric anastomosis. Gastrointest Endosc 2005;61:601–6. [51] Merrifield BF, Wagh MS, Thompson CC. Peroral transgastric organ resection: a feasibility study in pigs. Gastrointest Endosc 2006;63:693–7. [52] Pai RD, Fong DG, Bundga ME, et al. Transcolonic endoscopic cholecystectomy: a NOTES survival study in a porcine model. Gastrointest Endosc 2006;64:428–34.
ADVANCES IN SURGERY Endoscopy for the General Surgeon Brian R. Davis, MD, Gary C. Vitale, MD* Department of Surgery, University of Louisville School of Medicine, Louisville, KY 40292, USA
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ndoscopy plays an integral role in the diagnosis and treatment of complex pathology and is emerging as the treatment of choice for many diseases. There is an explosion of interest in endoscopy with its provision of less invasive therapeutics through natural orifices. Surgeons need to be imaginative and take the forefront in exploring the therapeutic potential of endoscopy in their practices with the emergence of natural orifice transluminal endoscopic surgery (NOTES). There is a resurgence of training in this field, and the future is full of potential. ENDOSCOPIC TREATMENT OF GASTROESOPHAGEAL REFLUX DISEASE Gastroesophageal reflux disease (GERD) places a high burden on the health care system and is a common and frequently underdiagnosed condition. Up to 40% of Americans have reflux once a month, 14% experience it once a week, and 7% experience reflux daily [1]. Endoscopic modalities for treatment have been developed to address the high cost of pharmacologic and surgical treatment of this disease. Current surgical procedures are not perfect, with up to 28% of patients requiring some form of drug therapy at 5 years of follow-up after Nissen fundoplication [2]. Endoluminal therapies can be divided into three categories treating the gastroesophageal junction reflux barrier through (1) endoscopic suturing/stapling, (2) radiofrequency treatment, and (3) injectable prostheses. The NDO Plicator The endosurgical NDO Full-Thickness Plicator (NDO Surgical Inc., Mansfield, Massachusetts) restores the antireflux barrier with a single plication of the cardia. This plication consists of a pre-tied implant that secures a full-thickness serosa-to-serosa union. The procedure uses a specialized endoscope with a tissue retractor that engages the gastric wall mucosa 1 cm distal to the Z-line. The arms of the endoscope are closed around the retracted tissue, and a single *Corresponding author. E-mail address: [email protected] (G.C. Vitale). 0065-3411/08/$ – see front matter doi:10.1016/j.yasu.2008.04.007
ª 2008 Elsevier Inc. All rights reserved.
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pre-tied 2/0 polypropylene suture is fired, creating a placation in the gastric cardia (Fig. 1). This suture is placed over two bolsters, and two titanium retention bridges keep it in place. Symptoms are improved by altering the angle of His, restoring the valvular mechanism of the gastroesophageal junction, and reducing the compliance of the cardia and fundus. A multicenter trial involving 68 patients demonstrated that 74% of patients were medication free and had a significant improvement in GERD-related quality-of-life scores and significantly decreased distal esophageal acid exposure 6 months after the NDO Plicator procedure. Pleskow and colleagues [3] performed a long-term multicenter follow-up study demonstrating that these improvements in heartburn-related quality of life were stable between 1 and 3 years of follow-up.
Fig. 1. NDO Surgical, Inc. Plicator. (A) Endoscopic Plicator device. (B) Stages of the plication procedure. (1) Visualization of the cardia. (2) Grasping the cardia. (3) Closing the plication jaws on the cardia. (4) Pretied pledgeted suture creates the plication. (5) Results after plication has been finished. (From NDO Surgical, Mansfield, Massachusetts; with permission.)
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Stretta procedure The Stretta (Curon Medical, Palo Alto, California) procedure uses the delivery of temperature-controlled radiofrequency energy to the muscle layer of the gastroesophageal junction. This procedure improves the objective and subjective parameters of GERD by creating a controllable degree of tissue contraction and compliance reduction. This procedure decreases transient lower esophageal sphincter relaxations by causing nerve ablation and collagen deposition that thickens the gastroesophageal junction. The Stretta catheter consists of a soft tip followed by a balloon with four needle electrodes that deliver radiofrequency energy. The treatment consists of four applications, each lasting 90 seconds, extending from 1 cm above the Z-line to .5 cm below the Z line. Using a pull-back technique, two additional levels of application are done in the cardia (Fig. 2). This technique should not be used in patients who have Barrett’s esophagitis, subnormal lower esophageal sphincter pressures, or significant hiatal hernias (> 2 cm). A multicenter prospective trial by Triadafilopoulos [4] involving 118 patients demonstrated that at 12 months’ follow-up 69% of patients had improvements
Fig. 2. Stretta procedure. (A) Lower esophageal sphincter before procedure. (B) Lower esophageal sphincter after radiofrequency treatment. (C) Stretta endoscopic treatment catheter (Curon Medical, Sunnyvale, CA).
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in both heartburn and GERD-related quality-of-life scores that were equal to or better than the improvements seen on baseline drug therapy. At baseline 88.1% of these patients used proton-pump inhibitor therapy; after this procedure, only 30% used drug therapy at 12 months. In a prospective trial, Richards and colleagues [5] at Vanderbilt compared the Stretta procedure with laparoscopic fundoplication. They found that 51% of patients treated with the Stretta procedure no longer required medication, and 31% had reduced their medication dose significantly, whereas 97% of patients treated with fundoplication had stopped using medication. The study with the longest follow-up evaluation (3 years) was by Lufti and colleagues [6], who demonstrated that 65% of 77 patients were not taking proton-pump inhibitors at 6 months, but this proportion fell to 43% at 3 years. The efficacy at 3 years was counted as 64% if the group included those not taking proton-pump inhibitors and those taking half their original dose of this medication, making the overall response to this treatment significant. When compared with the risks of surgery, the Stretta treatment seems to be an effective alternative to Nissen fundoplication. Gatekeeper reflux repair system The Gatekeeper reflux repair system (Medtronic Inc, Minneapolis, Minnesota) uses a radiopaque hydrogel prosthesis that is delivered endoscopically into the submucosa at the lower esophageal sphincter. A 16-mm overtube is passed over a wire after initial endoscopy. Suction then is applied to catch mucosa in a shelf, and after needle injection of saline into the mucosa. the dry implant is placed into the submucosa. Correct placement is checked with a miniprobe endoscopic ultrasound. Three hydrogels are placed while the patient is under conscious sedation. A multicenter prospective trial by Fockens and colleagues [7] involving 67 patients demonstrated a 75% improvement in heartburn-related quality-of-life scores at 6 months. These patients also demonstrated a statistically significant decrease in distal esophageal exposure time (from 9.1% to 6.1%) and an increase in lower esophageal sphincter pressure (from 8.8 to 13.8 mm Hg). EndoCinch suturing system The Bard EndoCinch 2 Suturing System (Bard, Inc., Cranston, Rhode Island) can be described as an endoscopic sewing machine, which requires two endoscopes for repeated intubations to complete the plications. A suturing capsule uses suction to capture tissue 1 to 2 cm below the Z-line. Once the tissue is captured, the handle is advanced, passing a suture through the tissue. This step is repeated a second time approximately 1 cm adjacent to the first stitch. Through the use of the second endoscope, the two suture lines are secured with an anchoring device by apposing the tissue together, thus creating a plication. These pleats reduce compliance and functionally narrow the gastroesophageal junction (Fig. 3). A large, prospective, multicenter trial of this procedure demonstrated that 62% of patients at the 3- and 6-month follow-up were taking less than four doses of medication per month. Significant improvements also were noted in
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Fig. 3. Endoscopic appearance using the Bard EndoCinch. (A) Appearance of lower esophageal sphincter before procedure. (B) Retroflexed view of sphincter before procedure. (C) Appearance of lower esophageal sphincter after procedure. (D) Retroflexed view after procedure. (From Bard, Inc., Cranston, Rhode Island; with permission.)
the heartburn severity score, the heartburn frequency score, and the regurgitation score [8]. Chadalavada and colleagues [9] performed a prospective trial demonstrating that the 32% of the group treated with the EndoCinch resumed drug therapy, whereas 13% of the group treated with laparoscopic fundoplication group resumed drug therapy. Enteryx The Enteryx System (Boston Scientific, Natick, Massachusetts) involves injecting a biocompatible co-polymer into the lower esophageal sphincter to alleviate GERD symptoms. The co-polymer is placed endoscopically in an intramuscular location under fluoroscopic guidance in a circumferential distribution at the
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lower esophageal sphincter. Injections are made 1 to 3 mm proximal to the Z-line in four quadrants (Fig. 4). The presence of this substance elicits an acute inflammatory reaction that creates a fibrous capsule that results in decreased lower esophageal sphincter muscle distensibility, thus altering the compliance of the gastroesophageal junction. After treatment, normal physiologic function of the esophagus resumes, allowing lower esophageal sphincter relaxation upon the ingestion of food. Long-term follow-up has shown that the Enteryx prosthesis is stable over time, and a prospective multicenter trial involving 85 patients has demonstrated an 80.3% response rate (defined as complete independence from medication or up to a 50% reduction in medication dosage at 1 year follow-up) [10]. In September 2005 the Food and Drug Administration recalled Enteryx because of adverse reports of injection into the mediastinum, pleural space, and aorta. It is possible that some improved variation of this technique may become feasible. Although most of these studies on endoscopic therapies exclude patients who have severe reflux, they provide evidence that these procedures are effective and safe for patients wishing to forego drug therapy for reflux disease. ENDOSCOPIC TREATMENT OF GASTROINTESTINAL BLEEDING Endoscopy is integral in the management of upper gastrointestinal bleeding and is able to identify the source of hemorrhage in more than 90% of lesions. Endoscopy reduces the incidence of emergent operations and the overall mortality from acute upper gastrointestinal bleeding. Treatments range from
Fig. 4. Cross-sectional view of cardia showing the Enteryx implant. (From Mason RJ, Hughes M, Lehman GA, et al. Endoscopic augmentation of the cardia with a biocompatible injectable polymer (Enteryx) in a porcine model. Mason RJ, Hughes M, Lehman GA, et al. Surg Endosc 2002;16:388.)
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banding esophageal varices to the use of clips and heater probes to address acute bleeding. Endoscopic pre-emptive therapy for esophageal varices is justified, given the high mortality rate (50%) from upper gastrointestinal bleeding at 1 year in patients who have advanced cirrhosis. Traditional sclerotherapy is giving way to endoscopic rubberband ligation of esophageal varices. Equal rates of hemorrhage control have been shown with banding and sclerotherapy, and banding has a lower incidence of stricture formation [11]. The banding device has multiple preloaded rubber bands that are released by a trigger after the mucosa has been sucked into the scope, thereby strangling the superficial venous vessels that thrombose and slough (Fig. 5). With band ligation, up to 75% of varices recur in 6 months. Repeat treatment is necessary. Peptic ulcers also commonly cause acute upper gastrointestinal bleeding. Ulcer bleeding can be treated by injection therapy in which dilute epinephrine (1:10,000) can be injected into the ulcer bed. Metallic clips can be applied with a special endoscopic applicator when bleeding vessels can be visualized directly. Contraindications to using clips include fibrotic ulcers, diffuse bleeding, large bleeding ulcers, and bleeding gastric cancers. Heater probes also have been developed that use heat and pressure to squeeze and seal the vessel, creating mucosal and submucosal coagulation and avoiding a full-thickness burn. After pressure occlusion, the probe applies multiple sequential pulses of 30 to 120 J to cause coagulation and thrombosis. A bipolar circumactive probe allows more precise control of the bleeding, provides irrigation of the bleeding point, and applies multiple short energy pulses given in rapid succession [12]. These short pulses cause less damage than monopolar cautery or yttrium aluminum garnet (YAG) laser therapy. The neodymium-doped (Nd):YAG laser and argon-beam coagulator have been useful for the treatment of bleeding angiodysplasias in the upper gastrointestinal tract.
Fig. 5. Esophageal varix band ligation with a multiband device. (From de Franchis R, Primignani M. Endoscopic treatments for portal hypertension. Semin Liver Dis 1999;19:443.)
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Combinations of these technologies have demonstrated no benefit in using banding and sclerotherapy together but demonstrated marked resolution of varices when banding was used with epinephrine injections and argon-beam coagulation for acute bleeding [13]. In peptic ulcer therapy, the combination of injection therapy with the heater probe has shown no benefit, but the use of injection therapy with argon-beam coagulation has been shown to be effective, especially when there is active bleeding or when an exposed vessel present [14]. Capsule endoscopy for gastrointestinal bleeding The reference standard for detection of occult gastrointestinal bleeding in inflammatory bowel disease has been intraoperative endoscopy. Before the use of endoscopes, the detection rate for occult bleeding lesions at laparotomy was as low as 30%, but the rate of detection has increased to 90% with the use of modern equipment. The least invasive challenge to the reference standard is capsule endoscopy. The Capsule Endoscope (Given Imaging, Yoqneam, Israel) contains a miniature metal oxide silicone chip video camera with four light-emitting diode illumination sources (Fig. 6). The image field of view is 140 , the magnification is
Fig. 6. Capsule endoscope. (From Given Imaging Ltd., Duluth, Georgia; with permission.)
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1:8, the depth of view is 1 to 30 mm, and the minimum size of lesion detection is 0.1 mm. A short focal length lens with a narrow aperture is used to increase the depth of the field. The capsule is swallowed and propelled by intestinal peristalsis. Images are obtained as the optical window of the capsule sweeps past the gut wall without requiring air inflation of the lumen. Video images are transmitted using radio telemetry (432 MHz) at a rate of two frames per second and are transmitted to eight sensors secured to the body. More than 50,000 images captured over an 8-hour period are stored in a digital recorder worn around the patient’s waist. The position of the capsule within the abdomen can be calculated by the strength of the signal relative to each sensor with an accuracy of up to 3 cm in the localization of visualized lesions. Capsule endoscopy has been compared with small bowel radiology. Enteroclysis has a diagnostic yield of 90% in patients who have small bowel tumors, but rate drops to 10% to 20% in detecting small bowel bleeding sources. Costamagna and colleagues [15] compared barium follow-through findings with capsule endoscopy for occult bleeding and inflammatory bowel disease indications in 20 patients. The capsule was considered to be diagnostic in 45%, compared with 27% in barium studies. Liangpunsakul and colleagues [16] used capsule endoscopy to assess 40 patients who had negative standard upper and lower endoscopy and normal radiologic studies. Abnormal findings were discovered in 83% of these patients; 63% had angiodysplasias, ulcers, or submucosal lesions. Capsule endoscopy provides visualization of these lesions that often are difficult to detect even when standard endoscopy can intubate the jejunum. Flexible endoscopes of sufficient length to intubate the proximal jejunum (push endoscopy) have been developed, and other scopes are carried into the distal small bowel by the action of peristalsis (Sonde endoscopy). Several prospective trials have demonstrated that capsule endoscopy has a better diagnostic yield than push endoscopy or Sonde enteroscopy in the detection of occult gastrointestinal bleeding. Mylonaki and colleagues [17] examined 50 patients prospectively and found that capsule endoscopy detected a small bowel source of bleeding in 68% of patients, whereas push endoscopy identified a source in only 32% of these patients. This study did note that the diagnostic yields of capsule and push enteroscopy are nearly identical when the jejunum is thought to be the source of bleeding. Prospective studies using capsule endoscopy as a first-line test in diagnosing the source of occult bleeding noted a decreased yield, with only 42% of studies being of diagnostic value, compared with its use in combination with standard endoscopy. Studies comparing intraoperative endoscopy with capsule endoscopy are underway. ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY Advances in endoscopic retrograde cholangiopancreatography (ERCP) have allowed minimally invasive approaches to interventions that normally carry a high morbidity and mortality in elderly patients and provide alternatives to
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pancreatic and biliary reconstructions that carry high risks of complications in patients who have chronic pancreatitis and gastrointestinal cancers. Endoscopic management of pancreatic pseudocysts ERCP has played a revolutionary role in managing the complications of pancreatitis. ERCP plays a beneficial role in defining the ductal anatomy in up to 80% of all pancreatic pseudocysts. Pseudocysts with favorable anatomy then can be drained endoscopically through the stomach or duodenum or through a transpapillary approach. Transenteric drainage routes are best suited for cysts that have well-developed walls that demonstrate indentation of the gastrointestinal tract or with demonstrated enteric adherence as determined by endoscopic ultrasound. Cyst-enteric drainage is optimal for pseudocysts with walls less than 1 cm thick when the ERCP demonstrates pancreatic ductal disruption or stricture. The transpapillary route should be considered when a stent can be placed directly through the duct into the pseudocyst after pancreatography demonstrates a communication between the pancreatic duct and the pseudocyst cavity [18]. Contraindications to the endoscopic procedure include ongoing pancreatic necrosis or suspicion of malignancy. In a series of 49 patients, De Palma and colleagues [19] demonstrated effective transmural drainage in 27 of 30 patients (90%) and effective transpapillary drainage 16 of 19 patients (84.2%). The University of Louisville experience documents a series of 59 patients with a total of 61 pseudocysts that were drained effectively endoscopically. This series included 30 cystgastrostomies, 11 cyst duodenostomies, and 24 transpapillary drainage procedures (Fig. 7). Complete resolution of the pseudocyst was achieved in 85% of patients. The Louisville experience also reports 34 patients who underwent endoscopic drainage for pancreatic abscesses associated with necrotizing pancreatitis. Abscesses were drained by
Fig. 7. Transgastric pancreatic pseudocyst drainage.
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cystgastrostomies [15], cystduodenostomies [4], and transpapillary drainage [16]. Endoscopic drainage of the pancreatic abscess was achieved in 80% of these patients [20]. These results prove that endoscopic drainage offers an effective therapeutic option with minimal morbidity and mortality. Endoscopic stenting for chronic pancreatitis The goals of endoscopic pancreatic duct stenting in chronic pancreatitis include pain control to allow nutritional rehabilitation and to resolve drug dependency issues and resolution of recurrent pancreatitis caused by ductal obstruction. The chronic pancreatitis pain syndrome is thought to arise from high intraductal pressures, perineural fibrosis, and a pancreatic compartment syndrome in which pancreatic scarring increases intraparenchymal pressure, thus decreasing blood flow. Pancreatic duct stenting for patients who have pancreatic duct strictures and pancreas divisum is believed to relieve high duct pressures and pancreas compartment syndrome. Farnbacher and colleagues [21] studied a series of 96 patients who had stenosis in the pancreatic duct treated by repeat stenting for a follow-up of 15 months. He reported a response rate of 82% with complete or partial relief of pain at 10 months and a response rate of 59% at 3 years. This study demonstrates that select patients who are early responders to pancreatic stent drainage are likely to benefit over the long term and that stent removal after stricture dilation may be associated with continued long-term pain relief. Coleman and colleagues [22] demonstrated that, in 34 patients who had pancreas divisum, stenting of the minor ampulla provided relief for 78% of those who had acute recurrent pancreatitis and for 60% of those who had chronic pancreatitis. The University of Louisville experience with pancreatic duct stenting for chronic pancreatitis demonstrates a response rate of 68%, with patients experiencing either no recurrence of pancreatitis or a less severe recurrence. Forty-seven percent of the patients reported a decrease in the use of pain medication, and 17% reported a significant weight gain after this procedure. This experience has demonstrated that the use of pancreatic duct stents reduces the intensity of chronic pain, the frequency of relapse, and the duration of pancreatitis in patients experiencing chronic pancreatitis (Fig. 8) [23]. Endoscopic therapy combined with thoracic splanchnicectomy has shown a unique efficacy in treating chronic pancreatitis. The Louisville experience with this
Fig. 8. (A) Pancreatic duct stricture. (B) Stricture with stent in the pancreatic and bile ducts.
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technique demonstrates a success rate of 68% (in 54 patients) in decreasing the intensity of pain and hospital admissions 1 year after surgery [24]. Endoscopic stenting for biliary strictures Endoscopic stenting after diagnostic ERCP also is a valuable tool in the management of biliary tract strictures. Strictures may be benign, arising from trauma (iatrogenic or accidental), chronic pancreatitis, sclerosing cholangitis, or stone disease (Mirizzi’s syndrome), or malignant, arising from cholangiocarcinoma, pancreatic carcinoma, or ampullary carcinoma. Benign strictures often result from iatrogenic injuries during cholecystectomy [25]. Biliary fistulae may occur from a cystic duct leak or an accessory hepatic duct as well as from a major duct injury. Bile duct stenting can decompress the biliary tract, allowing spontaneous closure of the leak. ERCP with stenting also plays a role in managing major hepatic duct and common bile duct injuries, draining the biliary tree before formal reconstruction. The University of Louisville experience over a 5-year period documented successful endoscopic management of 65 of 67 benign bile duct strictures of all origins, with resolution of symptoms and normal liver function tests after the procedure [26]. Long-term follow-up demonstrates a recurrence rate of 17%, which is similar to the long-term recurrence rates for surgical repair [27]. Long-term follow-up is necessary with both endoscopic and surgical management of these injuries to detect early recurrent stricture (Fig. 9). Malignant biliary strictures also are managed endoscopically for palliation. The University of Louisville experience over a 5-year period examined a series of 132 patients who had malignant biliary strictures managed with endoscopic therapy alone (69%), endoscopic and radiation therapy (11%), or surgical approaches (24%) [24]. The average survival in the surgical group was 16.5 months, compared with a 19 months in the endoscopic group. The total lifetime cost was $60,000 for surgery and $24,000 for endoscopic treatment [28]. For inoperable cancer, the preference has been to use metallic stents that have high patency rates and do not require multiple patient visits for stent changes (Fig. 10). The authors’ experience demonstrates that 31 of 34 metallic
Fig. 9. (A) Bile duct stricture after cholecystectomy. (B) Stenting of iatrogenic bile duct stricture.
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Fig. 10. Metallic stent in the common bile duct for a malignant stricture.
stents placed over a 4-year period remained patent until the patient’s death [29]. Recently, biliary stents have been placed temporarily while the patient undergoes chemoradiation treatment with the intent to resect the tumor in patients who have a good response. ENDOSCOPIC ENTERIC STENTING FOR MALIGNANCY Endoscopic therapy has been a mainstay for the palliation of esophageal cancer for a number of years, and recent trends in stenting demonstrate the benefits of duodenal stenting in unresectable pancreatic cancer and of colonic stenting of obstructive cancers for palliation or as a bridge to surgery. The largest retrospective study of palliative duodenal stenting, involving 176 patients, demonstrated a success rate of 98% with a complication rate of 14%. Eighty-four percent of these patients were able to resume oral intake for a median of 146 days [30]. Surgeons from Spain have reported a prospective study comparing duodenal stenting with gastrojejunostomy for the palliation of pancreatic cancer. They compared 24 cases of stenting with 17 cases of surgery. The length of hospital stay was 7.1 days for stenting versus 11.5 days for the surgery group, and the median survival was 20 weeks for stenting versus 21.6 weeks for the surgical group. Thirty-day mortality was 16.6% for the stented group and 29.4% for the surgery group, with complications of 4% and 17.6%, respectively. Efficient gastric emptying was seen in 100% of the stented group with a time to food tolerance of 2.4 days, whereas in the surgical group the rate of efficient gastric emptying was 82.3% with a time to food tolerance of 5 days [31]. Thus, duodenal stenting reduces the morbidity and improves quality of life in the palliative treatment of pancreatic cancer.
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Several groups have reported on the use of colonic stents in malignant colonic obstruction as a bridge to surgery and as palliation. Controversy surrounding this procedure relates to the perceived increased risk of metastasis and further invasion of the cancer. Tilney and colleagues [32] performed a recent meta-analysis on colonic stenting demonstrating that the use of colonic stenting as a bridge to surgery did not affect survival adversely. In this analysis of 10 studies and 244 patients, treatment with stenting proved successful in 92.6% of cases. Stenting provided a lower mortality rate than emergency surgery (5.7% versus 12.1%) and fewer complications than emergency surgery. Stenting of the colon is a safe and effective procedure for palliation and is a good bridge to surgical therapy, allowing a one-stage surgical procedure with curative intent. Endoscopic mucosal resection Endoscopic mucosal resection was developed in Japan in the 1980s by Tada and colleagues [33] for the treatment of early gastric and esophageal cancer. The initial technique is similar to that of resecting colonic polyps with submucosal injection of saline and snaring of the lesion. This technique has been applied widely only in Japan, where the early detection of gastric and esophageal cancer is high, and the prevalence of nodal metastasis is low. Inoue and colleagues [34] in Japan modified this technique by performing resection with the plastic cap used in band ligation of esophageal varices. The oblique-cut Inoue cap has a circular rim at the tip to accommodate a snare-wire loop. The lesion is injected, and the target lesion is covered with the cap. The snare wire then advances to form a loop along the rim of the cap. Suction draws the mucosa into the cap, and the lesion is strangulated by closing the pre-looped snare wire (Fig. 11). Electrocautery excises the tissue, and the specimen in withdrawn inside the cap for pathologic examination. Variations on this technique include band ligation using a standard variceal banding device that is able to perform en bloc resections of lesions up to 1.5 cm in diameter. After ligation, a standard polypectomy is performed below the rubber band with snare electrocautery. The newest innovation demonstrates en bloc resection of large mucosal lesions using lift-and-cut techniques with insulation tip diathermic knives [35]. ENDOSCOPIC ABLATION OF BARRETT’S ESOPHAGUS Barrett’s esophagus is a condition associated with GERD in which the normal stratified squamous epithelium of the esophagus is replaced by columnar epithelium. Barrett’s esophagus is a premalignant condition with an estimated risk of 0.5% per year of developing adenocarcinoma of the esophagus. Many studies have hypothesized that this condition progresses from a low-grade dysplasia to high-grade dysplasia and eventually to adenocarcinoma. The standard therapy for high-grade dysplasia has been esophagectomy. Less invasive approaches traditionally have included serial endoscopy with biopsy until high-grade dysplasia is found. This approach usually detects cancer at a curative stage, but the high mortality and morbidity rates for esophagectomy have led
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Fig. 11. Endoscopic mucosal resection. (A) Island of Barrett esophagus in proximal esophagus. (B) Barrett’s lesion tissue suctioned into endoscopic cap. (C) Snare cautery of lesion inside endoscopic cap. (D) Esophagus mucosa after resection of Barrett’s lesion. Lesion has not recurred.
to the development of endoscopic ablative therapies to eliminate the presence of Barrett’s esophagus and high-grade dysplasia. Initial attempts at ablative therapy to treat high-grade dysplasia and early cancer were reported by Overholt and colleagues [36], who in 1993 developed photodynamic therapy. This therapy involves administration of a photosensitizing pharmacologic agent followed by exposure to endoscopically delivered laser light. Prospective studies of this technique by Overholt and colleagues demonstrated a 75% efficacy in eliminating high-grade dysplasia durable up to 18 months, with 13% of patients progressing to cancer. Complications of this therapy include photosensitivity (69%) and esophageal strictures (36%). The rate of esophageal stricture in this study increased with repeat applications of photodynamic therapy, which were required in more than half of the patients in this study. Complications with this procedure and the need for
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multiple applications led to further innovation in the endoscopic treatment of Barrett’s esophagus. Effective destruction of Barrett’s esophagus has been achieved with the BARRX Halo-360 system (BARRX Medical, Sunnyvale, California). This system consists of an endoscopic balloon catheter attached to a radiofrequency generator that delivers short bursts of energy that circumferentially ablate a 3-cm area of tissue (Fig. 12). Fleisher and colleagues [37] reported initial results of this procedure demonstrating a 41% cure rate and a 54% partial response rate with no evidence of stricture formation. Sharma and colleagues [38] demonstrated a 70% complete response rate to radiofrequency ablation therapy at 1 year in 70 patients. This protocol delivers 10 J/cm2 to the Barrett’s esophagus (applications lasting 1 second) for a single treatment followed by repeat serial endoscopy and biopsy at 1, 3, 6, and 12 months. Patients found to have residual Barrett’s esophagus at biopsy underwent a second application of this treatment 3 months after the initial therapy. There were no complications from the use of this procedure; thus its efficacy and safety in prophylactic treatment of Barrett’s esophagus have been demonstrated. TRANSANAL ENDOSCOPIC MICROSURGERY Local excision as described in earlier sections also has been used for selected rectal cancers. Lesions in the mid and lower rectum first were addressed with transanal endoscopic microsurgery by Buess in 1982 [39]. This technique was used initially for excision of benign adenomas and palliation of cancer.
Fig. 12. The BARRX Halo 360 ablation catheter in place in the esophagus to treat Barrett’s esophagus. (From BARRX Medical, Sunnyvale, California; with permission.)
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Currently, transanal endoscopic microsurgery is used with curative intent for T1 tumors and is used routinely for palliation of T2 and T3 tumors. Operations are performed with multiple instruments within an operating endoscope, performing tasks such as suturing as high as 20 cm into the rectum. Full-thickness excision is performed to the pericolic fat, and the excision is closed transversely with a running suture. Patients often are discharged home the day of surgery with only minor postoperative sphincter dysfunction. Maslekar and colleagues [40] studied 52 patients who underwent transanal endoscopic microsurgery excision of a rectal cancer. Forty-two of these patients had T1 tumors, 8 had T2 tumors, and 2 had T3 tumors. Follow-up at 40 months demonstrated that the overall local recurrence rate was 14% and involved only T2 and T3 cancers. This study demonstrated that transanal endoscopic microsurgery is a safe and effective treatment for early rectal cancers that can reduce the morbidity and mortality of standard operative resections. Endoscopic bariatric surgery As endoluminal endoscopic techniques have evolved, the applications for bariatric surgery have become apparent. Obesity is an increasing health problem affecting a large portion of the United States population. With the high complication rate of laparoscopic bariatric surgery (12%–15%) and the high incidence of gastrojejunostomy leaks (2%–5%), a demand has developed for a less invasive procedure that can be performed under conscious sedation. Current interventions are used mostly for preoperative weight loss and for the treatment of postoperative complications [41]. Surgeons have advocated a two-stage approach to bariatric surgery to reduce the anesthesia risks in superobese patients. Endoluminal therapies are being used as temporary adjuncts to preoperative weight loss. Several surgeons have used the BioEnterics Intragastric Balloon (Allergan, Irvine, California) as a bridge to weight loss and as primary therapy for weight loss. Mathus-Vliegen and Tytgat [42] presented a long-term outcome study with balloon treatment that demonstrated that 70% of patients lost 15% of their body weight after a 3-month balloon treatment. Although these patients did regain weight after balloon removal, their weight at 1-year follow-up remained 9.9% below their prestudy weight. This finding argues for the use of temporary endoluminal gastric partitioning as a bridge to more formal gastric bypass in the superobese. Late complications after bariatric surgical procedures can include staple-line disruptions, dilation of the gastric pouch or stoma, stomal stenosis, anastomotic stricture, and enteric fistulas. Endoluminal techniques have been used to address these complications. Thompson and colleagues [43] treated patients who had a dilated gastrojejunal anastomosis and significant weight regain with the EndoCinch suturing system (Bard, Covington, Georgia). Plications were placed at the rim of the anastomosis, thus reducing the gastrojejunal aperture. Six of eight patients treated with this endoluminal therapy demonstrated a weight loss of more than 10 pounds at 4 months. Sclerotherapy also has been
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used to reduce the size of the gastrojejunal stoma, and fibrin glue has been applied endoscopically to treat gastrocutaneous fistulae. Endoluminal interventions are being developed in animal models to serve as primary, stand-alone weight loss therapies. Hu and colleagues [44] created a 30-mL gastric pouch using endoscopic suturing. Swain and colleagues [45] have developed the butterfly endoluminal gastroplasty procedure that involves the creation of a small gastric pouch with a restrictive outlet that can be adjusted endoscopically at a later date. Developing technologies include stapling systems to create limited gastric pouches, endoscopically delivered electric gastric stimulators, intragastric volume reduction devices, and endoscopically deployed sleeves that divert food through the duodenum. Significant technical hurdles still must be overcome before these therapies become viable alternatives to the gastric bypass for the growing problem of morbid obesity. There is little doubt, however, that an endoscopic approach that refines these techniques for treating obesity soon will be developed successfully.
NATURAL ORIFICE TRANSLUMINAL ENDOSCOPIC SURGERY Endoscopic techniques that sample tissues and drain collections through the enteric lumen have evolved into NOTES. Transluminal endoscopic techniques have been used since 1993 to drain pancreatic pseudocysts and abscesses. Seifert and colleagues [46] described endoscopic pancreatic debridement with a dormia basket through the stomach wall, which included removal of a necrotic spleen. These innovations have included unpublished reports of transgastric endoscopic appendectomy in humans in India [47]. These developments have led to an explosion of scientific interest in NOTES that is being tested in animal models and in patients throughout the world. NOTES has evolved from an exploratory procedure to formal organ resection. Models for abdominal exploration began with Kalloo and colleagues [48] at Johns Hopkins who developed a model for peroral transgastric surgery in pigs that has been used for liver biopsy. This group has developed animal models for transgastric cholecystectomy, splenectomy, tubal ligation, and gastrojejunal anastomosis. Bergstrom and colleagues [49] and Park and colleagues [50] in London also have developed animal models using endoscopic ultrasound as a tool for procedures ranging from treating reflux with transgastric sutures placed into the crura to endoscopically creating a gastrojejunostomy and cholecystogastrostomy. Merrifield and colleagues [51] and Pai and colleagues [52] have taken the development of this surgery further, ranging from a transgastric hysterectomy model to a transcolonic cholecystectomy model. The future holds exciting advances for endoscopy as a primary treatment modality for many diseases. These advances occur as the diagnostic technology in screening for diseases improves. Further involvement of the surgeon in these treatments will require collaborative efforts with interventional gastroenterologists. This collaboration in innovation and development ultimately will lead to
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the best care for the patient, expanding the range of therapeutic options for those faced with a wide range of common diseases. Acknowledgment The authors thank Judy Slaughter for her editorial assistance with this article. References [1] Locke GR, Talley NJ, Fett SL, et al. Prevalence and clinical spectrum of gastroesophageal reflux: a population based study in Olmstead County, Minnesota. Gastroenterology 1997;112:1448–56. [2] Liu JY, Woloshin S, Laycock WS. Late outcomes after laparoscopic surgery for gastroesophageal reflux. Arch Surg 2002;137:397–401. [3] Pleskow D, Rothsten R, Kozarek R, et al. Endoscopic full-thickness plication for the treatment of GERD: long-term multicenter results. Surg Endosc 2007;21:439–44. [4] Triadafilopoulos G, DiBaise J, Nostrant T, et al. The Stretta procedure for the treatment of GERD: 6 and 12-month follow-up of the U.S. open label trial. Gastrointest Endosc 2002;55:149–56. [5] Richards WO, Houston HL, Torquati A, et al. Paradigm shift in the management of gastroesophageal reflux disease. Ann Surg 2003;237:638–49. [6] Lufti RE, Torquati A, Kaiser J, et al. Three year’s experience with the Stretta procedure: did it really make a difference? Surg Endosc 2005;19:289–95. [7] Fockens P, Bruno MJ, Gabbrielli A, et al. Endoscopic augmentation of the lower esophageal sphincter for the treatment of gastroesophageal reflux disease: multicenter study of the Gatekeeper Reflux Repair System. Endoscopy 2004;36:682–9. [8] Filipi C, Lehman G, Rothstein R, et al. Transoral flexible endoscopic suturing for treatment of GERD: a multicenter trial. Gastrointest Endosc 2001;53:416–22. [9] Chadalavada R, Lin E, Swafford V, et al. Comparative results of endoluminal gastroplasty and laparoscopic antireflux surgery for the treatment of GERD. Surg Endosc 2004;18: 261–5. [10] Johnson DA, Ganz R, Aisenberg J, et al. Endoscopic implantation of enteryx for treatment of GERD: 12-month results of a prospective, multicenter trial. Am J Gastroenterol 2003;98: 1921–30. [11] Seewals S, Seitze U, Thonke F, et al. Interventional endoscopic treatment of upper gastrointestinal bleeding—when, how, and how often. Langenbecks Arch Surg 2001;38:88–97. [12] Blocksom JM, Tokioka S, Sugawa C. Current therapy for nonvariceal upper gastrointestinal bleeding. Surg Endosc 2004;18:186–92. [13] Cipoletta L, Bianco MA, Rotondano G, et al. Argon plasma coagulation prevents variceal recurrence after band ligation of esophageal varices: preliminary results of a prospective randomized trial. Gastrointest Endosc 2002;56:600–3. [14] Chau CH, Siu WT, Low BK, et al. Randomized controlled trial comparing epinephrine injection plus heat probe coagulation versus epinephrine injection plus argon plasma coagulation for bleeding peptic ulcer. Gastrointest Endosc 2003;57:455–61. [15] Costamagna G, Shah SK, Riccioni ME, et al. A prospective trial comparing small bowel radiographs and video capsule endoscopy for suspected small bowel disease. Gastroenterology 2002;123:999–1005. [16] Liangpunsakul S, Chadalawada V, Rex DK, et al. Wireless capsule endoscopy detects small bowel ulcers in patients with normal results from state of the art enteroclysis. Am J Gastroenterol 2003;98:1295–8. [17] Mylonaki M, Fritscher-Ravens A, Swain P. Wireless capsule endoscopy: a comparison with push enteroscopy in patients with gastroscopy and colonoscopy negative gastrointestinal bleeding. Gut 2003;52:1122–6. [18] Vitale GC, Lawhon JC, Larson GM, et al. Endoscopic drainage of the pancreatic pseudocyst. Surgery 1999;126:616–23.
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