10 reasons why surgeons should continue performing flexible endoscopy

Abstract

Diagnostic and therapeutic potentials of flexible endoscopy have been increasing. Several surgical procedures are now performed in flexible endoscopic platform. However, it is disturbing to find that only few surgeons are keen to acquire this expertise. Endoscopic skills are not optional but essential for every general surgeon. Sooner the surgical fraternity realise this, it is better for the prospects of future surgeons. Surgical societies should implement measures to highlight the importance of endoscopy training and strive to provide adequate training opportunities.

During this era of laparoscopic surgery, we find fewer surgeons competent to perform flexible endoscopic procedures. It is even rarer to find a passionate endoscopy trainer. Surgical societies globally have started recognising this disturbing trend and started implementing measures to highlight the importance of endoscopy training and providing training opportunities. Following are the top 10 reasons for surgeons to ponder and should pursue endoscopy training with resolve.

THIS IS WHAT OUR LEADERS WERE GOOD AT DOING…

Endoscopy is a field that has been developed by surgeons, to which surgeons have made, and continue to make major contributions. Endoscopic procedures such as colonic polypectomy by Dr. Shinya, endoscopic variceal banding by Dr. Steigman, biliary stenting by Dr. Nib Sohendra, percutaneous gastrostomy by Dr. Ponsky and per oral endoscopic myotomy by Dr. Inouve are some of the classical examples of how surgeons have been instrumental in developing several therapeutic endoscopic procedures.[1,2]

We should continue to do what our elders were good at and improve upon the art and science of flexible endoscopy and expand the scope of endotherapy with our continued commitment and innovation.

SURGEONS ARE BETTER PLACED IN PROVIDING NATIONWIDE GASTROINTESTINAL SERVICE

Indian subcontinent with more than 1.3 billion people needs enormous workforce to provide gastrointestinal (GI) services like screening for GI cancers, managing various GI disorders and treatment for advanced GI and hepatopancreatobiliary diseases. Relying on the service of gastroenterology specialists alone would be inadequate and untenable[3] General surgeons with basic flexible endoscopy skills are present throughout the country to take up this huge challenge of providing nationwide GI service efficiently.

BECOME A SMART SURGEON RATHER BEING A SALVAGE SURGEON

Most of the GI disorders can be initially managed by general surgeons. Like a captain of a ship, surgeon could decide about the further course of action in every clinical situation and involve the help and expertise of medical gastroenterologist and interventional radiologist and intensivist where and when required. Surgeons need not be called only in case of complications following endoscopic procedures like perforation and bleeding. He or she should take active part in the treatment algorithm rather than only called for salvage after a futile endoscopic intervention or complication. All GI bleeding cases and jaundiced patients can be discussed in a multi-disciplinary team meeting to define the treatment protocol with minimal access and maximum success. Given that many of the diseases identified at endoscopy are ultimately treated surgically, a surgeon's involvement in the early diagnosis and management is often optimal to assure continuity of care.

WITH BETTER HAND-EYE COORDINATION, SURGEONS CAN HAVE SHORTER LEARNING CURVE

Competence in flexible endoscopy depends on cognitive and technical skills and can be achieved by comprehensive structured endoscopy training courses. With open and laparoscopic surgical experience and better hand-eye coordination, surgeons are quick in grasping endoscopic skills. Surgeons usually have a better understanding of two-dimensional and three-dimensional anatomy.

Several studies have clearly demonstrated that surgeons are very competent in performing screening colonoscopy and polypectomy, even though the number of cases performed during their surgical residency is much less compared to gastroenterologist. With a better understanding of anatomy and pathology and good hand and eye coordination, surgeons could become masters in the art of flexible endoscopy with a shorter learning curve[4,5,6]

SURGEONS HAVE DIFFERENT PERSPECTIVES WHILE PERFORMING ENDOSCOPY

There are several studies highlighting the importance of preoperative endoscopy before upper GI and bariatric surgery. The presence of hiatus hernia, severe esophagitis and gastric pathologies would change the treatment algorithms. Moreover, there are several endoscopic weight loss procedures such as balloon deployment, sleeve gastroplasty to consider. Hence, a bariatric surgeon with flexible endoscopy skills would be better placed to perform pre-operative endoscopy in bariatric patients.

In gastric cancer, pre-operative endoscopy should ideally be done by operating surgeons, so that all the key details like the site and size of the tumour, how much tumour extension along the lesser curve and how close is the upper limit of tumour from cardia can also be clearly ascertained to enable in making ideal surgical strategy.

IMPORTANCE OF INTRA-OPERATIVE ENDOSCOPY

There have been increasing occasions during surgery when flexible endoscopy could come for surgeon's rescue. We could enumerate some classical situations. In case of redo laparoscopic Heller's myotomy, intra-operative upper GI endoscopy would help to confirm GE junction, adequacy of myotomy and also exclude any mucosal breach during the procedure. During laparoscopic bile duct exploration for multiple bile duct stones, intraoperative choledochoscopy would ensure completeness of stone removal before the closure of choledochotomy. Surgeons with endoscopy skills would be able to handle the flexible choledochoscopy more efficiently. Intraoperative laparoscopy-assisted small bowel enteroscopy could help to localise the site and source of obscure GI bleeding from small bowel. Hence, surgical team should be well versed with flexible endoscopy techniques for managing such challenging situations.

BENEFITS OF SURGEONS PERFORMING POST-OPERATIVE ENDOSCOPY

Periodic surveillance colonoscopy following previous colectomy for cancer colon or colonoscopic polypectomy can be better done by surgical team. Following laparoscopic fundoplication, post-operative endoscopy to look for adequacy of fundal wrap, any wrap migration, resolution of esophagitis and Barrett's oesophagus can all be assessed by the surgical team performing the procedure when indicated.

IMPORTANCE OF ENDOSCOPIC RESCUE FOR POST-OPERATIVE COMPLICATIONS

Flexible endoscopy has immense therapeutic potentials both during early and late post-operative periods following many abdominal procedures. Following are some classical examples.

• Any bleeding from bowel anastomotic sites could be visualised and if needed appropriate endoscopic haemostatic procedure can be done to treat the complication efficiently

• Endoscopic CRE balloon dilatation for stricture at gastric bypass site

• Endoscopy-assisted suture narrowing of wide RYGB anastomotic site to manage regain of weight

• Endoscopic deployment of fully covered beta stent in case of post-sleeve gastrectomy leaks.

SCARLESS SURGERY COULD BE NATURAL CHOICE BY OUR PATIENTS

From the era of open surgery now, we have moved on to era of minimal access surgery. What was accomplished by big incision and big surgery can now be easily performed by small incision or incisionless surgery. It is paramount that surgeons are now well versed with all facets of surgery so that he or she could offer the ideal treatment modality as per the need of the clinical scenario. Scarless surgery on flexible endoscopy platform is the future as there is increasing number of endoscopic treatment options for several surgical conditions. Hence, this is obviously going to be an attractive choice once safety and efficacy are proved and ease of performance is improved.

EXPANDING LIST OF CONDITIONS WHERE IN ENDOTHERAPY COULD VERY WELL BE BETTER ALTERNATIVE…

With arrival of technological innovations such as HD endoscopy with image enhancement and magnification, various endoscopic accessories and energy sources, several surgical procedures are now feasible on flexible endoscopic platforms.

Peroral endoscopic myotomy instead of Laparoscopic Heller's myotomy, percutaneous endoscopic gastrostomy instead of open feeding gastrostomy, endoscopic sleeve gastroplasty in place of laparoscopic sleeve gastrectomy and endoscopic drainage of pseudopancreatic cyst are some of the classical examples.

Hence, advanced therapeutic endoscopic procedures are within the purview of general surgeons with adequate training and appropriate team approach.

To conclude, endoscopy skills are very essential for every surgeon. Like a knife to cut and laparoscopy to visualise and operate, now endoscopy has become another important tool for surgeon to master. Surgical fraternity should continue to train themselves and their juniors in the art and science of endoscopy as scarless surgery has bright future.

Surgical fraternity and surgical associations should take appropriate measures to provide the young surgeons with accredited endoscopic training program in the near future.

Structured training program for surgeons in the art and science of endoscopy is the need of the hour. There is a lot of scope with flexible endoscopy for surgeons.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.