Endoscopy is evolving. Innovations in the emerging field of interventional endoscopy have transformed a routine diagnostic procedure into the next generation of minimally invasive surgery. As a result of this rapid innovation, the American College of Gastroenterologists and the American Society of Gastrointestinal Endoscopists have placed a high priority on ensuring competence in new endoscopic skills. In this article, with the guidance and input from two experts in the field, Dr. Bertrand Napoléon and Dr. Vincent Lepilliez from Jean Mermoz Hospital in Lyon, we’ll tell you more about exciting innovations in endoscopy.
New Techniques in Therapeutic Endoscopy
Endoscopy has been the “go-to” diagnostic procedure in the field of gastroenterology for decades. However, its application has been limited to making a preliminary diagnosis, taking samples, and then waiting hours or days for pathology findings. Delays in treatment can be virtually eliminated through new innovations in therapeutic endoscopy.
Using precise techniques and innovative new tools that rival those used in microsurgery, targeted therapies can be delivered almost immediately after a diagnosis is confirmed. As more and more endoscopists get trained and master the latest tools and techniques, diagnosis and treatment of GI lesions will soon be combined seamlessly in one procedure.
Endoscopic Submucosal Dissection (ESD)
Endoscopic Submucosal Dissection is an innovative advanced endoscopic approach to superficial gastrointestinal neoplasms” that “has the potential to revolutionize treatment of early alimentary cancers” notes Dr. Jonah Cohen in the Journal of Diagnostic and Therapeutic Endoscopy. Endoscopic Submucosal Dissection allows you to move beyond routine procedures such as polypectomy or endoscopic mucosal resection and make immediate therapeutic interventions.
With ESD, endoscopists can identify, mark and dissect the lesion in one sequence, then lift the lesion by injecting a simple hyperosmolar solution. Once lifted, a circumferential incision is made around the lesion with a miniaturized electrosurgical device through the endoscope, followed by submucosal dissection at the microvascular level.
The endoscopic submucosal dissection technique allows patients to go home on the same day we operate them. – Dr. Lepilliez
Samples are then sent to the lab for routine anatomical and pathological examination. Given the technical difficulty of ESD and the risk of perforation, repeated practice on animal models is essential before performing this technique on patients. “One key benefit from this procedure, when it is well mastered, is that it can be done in an outpatient setting” explains Dr. Lepilliez.
Endoscopic full-thickness resection (EFTR)
Endoscopic full-thickness resection (EFTR) is a powerful technique for diagnostic tissue acquisition that will soon enter standard clinical practice. EFTR refers to the resection of a gastrointestinal (GI) lesion involving all layers of the endoluminal GI tract (conventional resections are restricted to superficial layers of the GI wall.)
However, as explains Dr. Vincent Lepilliez, a gastroenterologist and hepatologist, most EFTRs are performed for lesions that reach into the submucosa or deeper muscular layers. Since full thickness resection creates an orifice that exposes the contents of the peritoneum or adjacent organs, the defect must be tightly closed to prevent spillage of the contents outside the luminal GI tract.
With the aid of over the scope clips (OTSCs) such as the Ovesco clip, a specialized tool for use in the colon and the rectum, endoscopists can perform full thickness wall closure, with or without laparoscopic assistance, and avoid risky surgery in some patients. New OTSCs are stronger than conventional clips and provide better tissue capture, so they can grasp, lift, and resect lesions of 2cm or less all within the confines of an applicator cap that is installed on the flexible endoscope.
Endoscopic Pancreatic Necrosectomy
For patients with acute pancreatitis, endoscopic pancreatic necrosectomy is a real revolution, according to Dr. Napoléon. It is a new, less invasive intervention for removing the necrotic collection that remains after a pancreatitis episode. Instead of standard surgery via the transgastric route, necrosectomy is performed directly through the stomach or duodenal wall. While this procedure may require multiple interventions, approximately 90% of patients experience complete resolution of their symptoms after their series of treatments.
The endoscopic pancreatic necrosectomy technique has been a ground breaking innovation for interventional endoscopy.- Dr. Napoléon
Compared to the surgical approach, the procedure is minimally invasive, allows for easier access to the necrotic cavity, and does not require complex post-surgical management. Given the level of endoscopic expertise required, however, this procedure should be conducted only by experts, in high volume specialized medical centers.
Confocal Laser Endomicroscopy and Endocytoscopy
Confocal laser endomicroscopy and endocytoscopy are emerging endoscopic technologies that permit high-resolution assessment of gastrointestinal mucosal histology at a cellular and sub-cellular level. These technologies are able to obtain “optical biopsies” of nearly any endoluminal surface in real time. Confocal laser endomicroscopy (CLE) is based upon the principle of illuminating a tissue with a low-power laser and then detecting fluorescent light reflected from the tissue. Intravenous and/or topically applied contrast agents are required to illuminate the tissue and highlight its vasculature, lamina propria, and intracellular spaces.
Endocytoscopy (EC) is an ultra-high magnification technique that provides images of surface epithelial structures at cellular resolution (up to 1400-fold). It is mainly used as an adjunctive technique given its restrictive sampling area. Both technologies are available in two versions: integrated into a standard, high resolution endoscope or as a probe-based system which is inserted into the working channel of the endoscope. Leaders in the field include Bertrand Napoléon, Marc Giovannini and colleagues who have studied needle-based confocal laser endomicroscopy in pancreatic cystic lesions.
These new endoscopic technologies help us to see what we could not see before. When, with conventional endoscopy, we used to observe tissues, now, with pCLE and Endocytoscopy, we can analyze the living cells. – Dr. Napoléon
A consensus team that included experts David L. Carr-Locke and Kenneth K. Wang, among others, have also been instrumental in promoting guidance on probe based CLE in conditions such as Barrett’s esophagus, biliary strictures, colorectal lesions and inflammatory bowel diseases. The 26 panellists agreed that pCLE should be used “to enhance the diagnostic arsenal” and “improve the diagnostic performance of the physician” in the evaluation of gastrointestinal diseases; to do so, however, requires “standardized initial and continuing institutional training programmes.”
What’s exciting about these technologies is that “It helps [us] to see what we could not see before” according to Dr. Napoléon. “We can analyze the living cells and detect their abnormalities before a tumor is visible.” Indeed, confocal laser endomicroscopy and endocytoscopy are groundbreaking tools in the field of gastroenterology. They have already shown promise in assessing colon polyps, Celiac disease, and conditions such as Barrett’s esophagus and ulcerative colitis.
A recent article on confocal endomicroscopy by Dr. Carlos Robles-Medranda suggests that it’s time to move on from traditional histopathology. It mentions a 20-30 % misdiagnosis rate of this current standard compared to the high accuracy rate, reduced procedures, and reduced costs of CLE. He notes that it is possible to overcome the challenges of physician training for image interpretation, as well as other administrative barriers.
Innovations for your Surgical Toolbox
Rapid advances in the endoscopic field mean two things: new tools and new skills to learn. But precision requires practice. Those who master these tools and techniques will be among the select few to lead the next generation of endoscopic technology. Here are several up and coming tools that can make your surgeries simpler, safer, and more straightforward.
The ESD Scalpel
This new type of scalpel, the latest in a series of “energy based surgical devices” (ESDs), combines high-pressure water injection with electrocoagulation, eliminating the need to switch between cutting and coagulation tools, for a safer procedure as explains Dr. Vincent Lepilliez. More importantly, with no sharp knife involved, the risk of penetrating the mucosal tissue is virtually eliminated.
This new type of scalpel prevents endoscopists from switching tools. The result? The procedure is safer for the patients. – Dr. Lepilliez
The Radiofrequency Probe
This high tech wand, which is essentially an “echoendoscope”, facilitates the removal of diseased tissue by special needles that puncture the digestive wall to provide direct access to the diseased organ. The probe has already shown promise in treating liver disease and lung metastases.
The “Triangle” Endoscope
Inspired by the triangulation surgical repair technique, the triangle endoscope is designed to have three “arms”, which allow better visibility during endoscopic interventions. This tool is still under development, but prototypes have already been created.
The Challenge: How to Get Trained Efficiently on These New Techniques?
As you can see, innovations in therapeutic endoscopy are coming rapidly, often through incremental changes in previous tools and techniques. To know more about these advances and innovations, training seminars and masterclasses are held on a regular basis, such as the one organized by Northwestern University in Chicago. If you want to go an extra step and be among the first to use them, you might want to take an in situ training course listed on dedicated platforms such as www.invivox.com to sharpen your skills.
In such training, an Expert surgeon, such as Dr. Napoléon or Dr. Lepilliez, will host you for a unique peer-to-peer mentoring experience. This experience will allow you to discover these tools and techniques in a real life setting. Potentially, it will give you confidence to implement some of the latest surgical techniques in your own practice.