Palaniappan's   ENDOSCOPIC INETERVENTION   GASTROENTEROLOGY PRESENT SCENARIO

Indeed 21^st century looks bright and exciting in the field of Gastrointestinal Endoscopy.

 Interventional  endoscopy is evolving into its own subspeciality.

Advances in endoscopy techniques and devices have led to a variety of new exciting applications for endoscopy and minimally invasive endoscopic surgical procedures

ENDOSCOPIC ULTRASOUND   [ EUS ]

Eus  is the most accurate imaging modality for staging GI tumors  Retroperitoneal  and Mediastinal masses. Re orientation of Ultrasound transducer on the echoendoscope allows for fine needle aspiration of these masses and cysts trans luminally   as opd procedure all  under monitored anaesthesia with increased diagnostic accuracy. Its less invasive less costly eliminating need for surgery.EUS thus has significantly helped to differentiate benign from malignant lesions and is also the procedure of choice when tissue acquisition fails.EUS thus leads to more effective and efficient medical and surgical management

ENTERAL STENTING 

Self expandable metal  stents  for palliation of malignant luminal   [Esophageal  Gastro Duodenal  Colonic ]  or biliary  obstruction.Its the modality of choice for Tracheo Esophageal Fistula

ENDOSCOPIC HEMOSTASIS

New endoscopic accessories and coagulation devices are available to address complex bleed of GI mucosal or vascular origin,post polypectomy bleed,or mucosal  gap defects that are spontaneous perforation or secondary to endoscopic  resection or therapy.Bleeding mucosal AV Malformations or Radiation Proctitis can be addressed with Argon Plasma Coagulation modality which was available only for surgical use

Bleeding varices controlled by Band ligation devices Glue therapy Metal stenting thus avoiding a potentially life threatening scenario

ENDOSCOPIC MUCOSAL RESECTION  [EMR]

GI tract is home to some of the deadly human diseases.Exacerbating the problems is the difficult of accessing it for diagnosis or intervention and the concomitant discomfort to patients besides expenses.Diagnosing and treating these maladies was challenging for many years but technological innovation has continually improved our ability in helping our patients

In the recent few years EMR is a familiar technique in our part of the world though in vogue for more than 15yrs in Japan .EMR is for superficial GI neoplasms precancerous lesions which have no node spread.Thus organ is preserved and as well curative therapy achieved in par to Surgical therapy.

To study these early lesions we have High Resolution endoscopy, Magnification endoscopy ,Dye based mucosal endoscopy called chromoendoscopy.These modalities delineate normal from abnormal mucosa guide in biopsy sampling to avoid sampling errorsand  sometimes to avoid bx if its s/o benign lesion and in advanced way to resect them too. Endoscopic Sub mucosal Dissection[ESD] is  advancement of EMR technique for one piece resection of superficial mucosal  lesions which is a labourious and highly complex procedure routinely done in eastern part of the world now being introduced in other parts of the world

STANDARD ENDOSCOPIC PROCEDURES

 Gastroscopes      for  Esophagus Stomach and Duodenum screening and therapy

Duodenoscope   for side viewing scopy of Ampulla in D2  and ERCP towards   Biliary / Pancreatic endotherapy.This includes Bile duct                                                                                                                                                                                                                                                stone clearance    stricture  dilation    leak management post surgery or trauma .Pancreatic stone stricture  leak management

Colonoscope   for complete screening of colon upto Terminal Ileum as diagnostic and therapeutic aspects

Enteroscope [Single and Double Balloon] for screening small bowel in c/o occult GI bleed unexplained diarrhea small bowel tumors Inflammatory bowel disease

SpyGlass scope for direct viewing of lumen of biliary and pancreatic lumen and also in therapy

Wireless Capsule Endoscope is a miniature pill sizes camera swallowed which screens small bowel where bi directional scopy is normal in c/o GI bleed or chronic diarrhea                                                                  24Hr Ph study  for Esophageal Reflux disease    Manometry study for Achalsia Cardia / GERD and other motility disorders of Esophagus are routine prerequisites prior to Surgery for these issues

THIRD SPACE ENDOSCOPY   ENDOSCOPIC ONE HANDED SURGERY

This is the final frontier in Endoscopy in vogue only few years since.We all know GI lining mucosa is  layered like mucosa submucosa muscularis propria and serosa.Lesion in submucosa can be accessed with endoscope, tumors can be acessed by a mucosal rent made endoscopically submuosal space is accessed and tumor  removed and mucosal rent issealed with  clips with no perforation or surgical need as muscularis layers are not breached at all.                                                                                                               Thus Per Oral Endoscopic Motomy[POEM] is done for Achalasia Cardia   PerOral Endoscopic PyloroMyotomy for Gastroparesis  Per Rectal Endoscopic Myotomy PREM for Hirschprungs Disease are all recent advancements in the field of Endoscopy

LIMITATIONS OF ENDOSCOPY

Adverse events related to sedation besides bleed perforation and infection.Currently advancements in devices enable to seal perforation with clips or loops endoscopically thus precluding surgery.This is applicable to luminal bleed complications