Falk Symposium 166GI Endoscopy – Standards & Innovations

18. – 19. September 2008, Mainz

Milestones in GI endoscopy:A pioneer reflects

Nib SoehendraKlinik und Poliklinik für Interdisziplinäre Endoskopie

Universitätsklinikum Hamburg-Eppendorf

Size of the diagnosed gastric early cancer

1950 1960 1970 1980 1990 2000 2010

ZOOMChromoLIFE OCT EUS

Gastrocamera

2-3 cm

Fiberscope

1-2 cm1 cm

Videoscope

0.5 cm

Exera

Lucera NBI,

Micro-, Bio-Endoscopy

ECS

NBI of a tubular adenoma of the colon NBI + Magnification

Narrow Band Imaging (NBI)

Machida H et al. Endoscopy 2004;36:1094-8

ECS (Endo-Cytoscopy System)

Okuyama Y et al. Gastroenterol Endosc 1967;9:42-3Kozu T et al. Gastroenterol Endosc 1975;17:810-7Inoue H et al. Digest Endosc 1996;8:134-8

ECSHigh & Low resolution type

Oral mucosa (magnification 1100x)

Oral mucosa (magnification 450x)

Olympus

Confocal EndomicroscopeInoue H et al. Endoscopy 2000;32:439-43

In vivo study of neoplastic colorectal lesions (with i.v. fluorescein):

• Sensitivity 97.4%

• Specificity 99.4%

• Accurary rate 99.2%Kiesslich R et al. Gastroenterology 2004;127:706-13

Kiesslich R et al. Gastroenterology 2004;127:706-13

Colon cancer. (A) Confocal laser endomicroscopy shows irregular cell architecturewith total loss of goblet cells. (B) Corresponding histologic specimen.

AF Videoscope (2CCDs)AF CCD

Std CCDfor white light

endoscopy

LightGuide

LightGuide

biopsy

Olympus

Optical BiopsyVirtual Histology

Bio Endoscopy

Therapeutic Endoscopy• Foreign body extraction• Bougienage• Pneumatic dilatation• Botox injection• Esophageal stenting• Hemostasis • Variceal obliteration• Band ligation• Antireflux procedures• PEG• Mucosal resection (EMR)• Submucosal dissection (ESD)• Septotomy of Zenker• Klipping of perforation• Sealing of fistula

• Biliary sphincterotomy• Biliary stone extraction• Mechanical lithotripsy• Intraductal lithotripsy• Biliary stenting• Drainage of gallbladder• Pancreatic sphincterotomy• Pancreatic stone extraction (ESWL)• Pancreatic duct stenting• Pseudocyst drainage (EUS guided)• EUS guided neurolysis• Drainage of abscess• Papillectomy• Polypectomy• Colorectal, Duodenal stenting

In the early 90´sThe first rigid endoscopic foreign body removal

Guisez J. Traité des maladies de l‘oesophage. Baillière, 1911Starck H. Lehrbuch der Ösophagoskopie, Kurt Kabitsch 1914

Jackson Ch. JAMA 1921;76:577

Safety-pins in stomach. Peroral gastroscopic removal withoutanesthesia.

1939The first sclerotherapy of esophageal varices

Crafoord C & Frenckner PActa Oto-Laryngologica 1939;27:422-9

Palmer EDThe vigorous diagnostic approach to upper gastrointestinaltract hemorrhage. (1400 patients from 1946-1969)JAMA 1969;207:1477-80

The 1st Consensus Development Conference on Gastrointestinal Endoscopy and 1st Role in Upper

Gastrointestinal Bleeding

Upper gastrointestinal fiberoptic panendoscopy was the most sensitive and specific method to identify the causative lesions and their locations in most patientswith recent or ongoing upper gastrointestinal hemorrhage, to confirm or exclude the presence of clinically suspected lesions, and to evaluate bleedingversus non-bleeding lesions that might be present

Augusta 1980

1976 Injection HemostasisSoehendra N, Werner B.New technique of endoscopic treatment of bleeding gastric ulcer. Endoscopy 1976;8:85-7

Asaki S et al.Endoscopic hemostasis of gastrointestinal hemorrhage by local application of absolute ethanol: a clinical study.Tohoku J Exp Med. 1983;14:373-83

Hirao M et al.Endoscopic local injection of hypertonic saline-epinephrine solution to arresthemorrhage from the upper gastrointestinal tract.Gastrointest Endosc 1985;31:313-7

Chung SCS, Leung JWC et al.Endoscopic injection of adrenaline for actively bleeding ulcers: a randomized trial.Br Med J 1988;296:1631-3

1987

Editorial by Bernard M. SchumanEndoscopic injection therapy for nonvaricealupper gastrointestinal hemorrhage –Is it too good to be true ?

Commenting the paper by:Leung JWC, Chung SCS.Endoscopic injection of adrenalin in bleeding peptic ulcers.Gastrointest Endosc 1987;33:73-5

Endoscopic Hemostatic Methods• Thermal

– Bipolar Coagulation (BICAP)– Heater Probe– APC– Hemostatic forceps (monopolar coagulation)

– (Laser)

• Injection• Mechanical

– Clip – Ligation

Hachisu T. Evaluation of endoscopic hemostasis using an improved clipping apparatus.Surg Endosc 1988;2:13-17

Hachisu T. A new detachable snare for hemostasis in the removal of large polyps or other elevatedlesions.Surg Endosc 1991;5:70-4

1986Cyanoacrylate for controlling variceal bleedingRamond MJ et al. Gastroenterol Clin Biol 1986;10:575

Soehendra N et al. Endoscopy 1986;18:25

Esophageal varices III° Day 4 after 1. EVL

Day 7 after 2. EVL 3 weeks after 2 EVL

1989 Stiegmann GV et al. Endoscopic variceal ligation1996 Saeed ZA et al. „The Six-shooter“

Wolff WI & Shinya HThe first colonoscopic polypectomy was performed at the Beth Israel Medical Center in New York in September 1969Wolff WI, Shinya H. A new approach to colonic polyps. Ann Surg 1973;178:367-78 (report on 499 polypectomies in 350 pts.)

Niwa H8. Kanto Branch Meeting of Japan GE Society

1969 the first polypectomy in the colon

Snare Polypectomy

• Rectum/Colon• Stomach• Esophagus• Duodenum (papillectomy)• Small bowel

Techniques of EMR• Lift and Cut using a double-channel endoscop

(Tada et al. Gastrointest Endosc 1984)

• Suck and Cut using an overtube(Makucchi et al. Jpn J Surg Gastroenterol 1991)

• Suck and Cut using a cap(Inoue et al. Surg Endosc 1990)

• Suck and Cut using single band ligator(Chavez et al. Gastrointest Endosc 1994)

• Simple Snare Resection without any addtional tool(Soehendra et al. Endoscopy 1997)

• Suck and Cut using multiband ligator („DUETTE“) (Soehendra et al. Gastrointest Endosc 2006)

MBL-EMR DeviceDUETTE TM

RF HALO Ablation System, BARRX

En bloc EMR in the Stomach

Courtesy from H. Ono

ESD (Endoscopic Submucosal Dissection)

Endoscopic Submucosal Dissection(ESD)

IT-knife Ono Hook knife Oyama

TT knife Inoe Flex knife Yahagi

Flush knife Toyonaga

UndiffrentiatedAdenocarcinoma

DifferentiatedAdenocarcinoma

Any size<3cmAnysize

>2cm≤2cm

>sm1sm1UL(-/+)

UL(-) UL(+)

T1smT1mDepth of Invasion

Histology

Japanese concensus for EMR Extended indications for EMR

Surgery Clinical trial

Extended Indication for Gastric EMR in Japan

1973 The First Endoscopic PapillotomyKawai K et al. J Kyoto Pref Univ Med 1973;82:353Classen M, Demling L. Med Tribune 1973; 8:27

1983 Endoscopic Papillary Balloon Dilation (EPBD) Staritz M et al. Endoscopy 1983;15:197-8

N 15 ptsSuccessful stone extraction 100 %Mechanical Lithotripsy 44 %

Endoscopic Papillary Balloon Dilation(for removing small stones in patients with coagulopathy)

Endoscopic papillotomy + Balloon sphinteroplasty

for removing large CBD stones(Stone clearance rate: 95%)

Maydeo A, Bhandari S. Endoscopy 2007;39:958-61

Endoscopic extraction of giant CBD stones- Milestones -

• Nakajima N, Akasaka Y, Fukumoto K et al.Peroral cholangiopancreatoscopy (PCPS) underduodenoscopic guidance. Amer J Gastroenterol 1976;66:241-7

• Yamakawa T, Komako F, Shikato J.Biliary tract endoscopes. Gastrointest Endosc 1978;24:110-13

• Koch H, Rösch W, Walz V.Endoscopic lithotripsy in the common bile duct. Gastrointest Endosc 1980;26:16-8

• Demling L, Seuberth K, Riemann JF.A mechanical lithotripter. Endoscopy 1982;14:100-101

• Sauerbruch T, Stern M.Fragmentation of bile duct stones by extracorporeal shockwave lithotripsy. Gastroenterology 1989;96:146-52

My first mechanical lithotripsy

Electrohydraulic Lithotripsy (EHL)

Nakajima N, Akasaka Y, Fukumoto K et al. Peroral cholangiopancreatoscopy(PCPS) under duodenoscopic guidance. Amer J Gastroenterol 1976;66:241-7Koch H, Rösch W, Walz V. Endoscopic lithotripsy in the common bile duct. Gastrointest Endosc 1980;26:16-8

PABLO L. MIRIZZI (1893 - 1964), surgeonCórdoba, Argentina

Mirizzi´s Syndrome is no longer

a surgical indication

Transpapillary intraductal lithotipsy

1976 Naso-biliary drainageNagai N et al. Gastrointest Endosc 1976;23:78-81

Naso-biliary drainage using a 5F catheter

The first endoscopic biliary stenting using a side-viewing gastroscope GF B2 Olympus

1979Endoscopic Biliary StentingSoehendra N, Reynders-Frederix VDtsch med Wschr 1979;104:206

1988: Invention of expandable Metallic Stent

• Gianturco Cook• Wallstent Medivent• Strecker Meditech• Nitinol (memory alloy) Olympus

Irving JD, Adam A, Dick R, Dondelinger RF, LunderquistA., Roche A. Gianturco expandable metallic stents. Result of a European clinical trial (in 16 pts with malignant and 11 ptswith benign strictures). Radiology 1989;172:321

1982 Frimberger E. et al. Spiralprothese für den Gallengang. Dtsch med. Wschr. 1982;107:1985-6

- Z-Stent (Gianturco)- Wallstent- Diamond- Za-Stent- Zilver Stent- Taewoong- Shim-Hanaro- Bonastent- Ella stent- Ecostent

Selfexpandable Metallic Stent

SEMS for palliationof malignant obstruction

• Esophagus• Biliary duct• Gastric outlet• Rectum/Colon• Small bowel

1885The first plastic stent placement in the esophagusSymonds CJ. Transactions of the Clinical Society of London 1885;28:155

Celestin LR. Ann Roy Coll Surg 1959;25:165-70Boyce HW. Geriatrics 1973;28:97Tytgat GNJ et al. Endoscopy 1976;8:180-5Atkinson M, Ferguson R, Parker C. GUT 1978;19:669-71

1983 First metallic stent in the esophagus

Frimberger E. Expanding spiral – a new type of prosthesis for thepalliative treatment of malignant esophageal stenoses. Endoscopy 1983;15:213-4

First biliary metallic stentFrimberger E. Endoscopy 1983;15:213-4

The Nottingham Introducer

Atkinson M, Ferguson R, Parker C. GUT 1978;19:669-71

First endoscopic stent placement in the esophagusTytgat GNJ et al. Endoscopy 1976;8:180-5

1980 The first PEGGauderer MWL, Ponsky JL, Izant RJ Jr.J Pediatr Surg 1980;15:872

1980 Endoscopic ultrasoundDiMagno EP et al. Lancet 1980;1:629-31

EUS equipment to date

Therapeutic EUS• EUS-guided Drainage Cystenterostomy

Grimm H et al. GIE 1992;38:170-1Seifert H et al. Endoscopy 2000;32:255-9Seewald S et al. GIE 2005;62:92-100

• EUS-guided NeurolysisWiersema MJ et al. GIE 1996;44:656-62

• EUS-guided biliary and pancreatic stentingGiovannini M et al. Endoscopy 2001;33:898-900Francois E et al. GIE 2002;56:128-33Tessier G et al. GIE 2007;65:233-41

• EUS-guided gastro-enteroanastomosisFritscher-Ravens A et al. 2003;58:585-91

• EUS-guided antitumortherapyChang KJ Endoscopy 2006;38(S1):S88-93

EUS-guided Cystgastrostomy & Endoscopic Necrosectomy

2002 Endoscopic Endoscopic SuturingSuturing DeviceDeviceSwainSwain CP CP et al. et al. GastrointestGastrointest EndoscEndosc 1986;32:361986;32:36--77

DeMeester

Enteryx

Stretta

Gatekeeper

Endocinch

Shaheen NJ. Gastroenterology 2006;131:952-4

The Rise and Fall (and Rise?) of Endoscopic Anti-Reflux Procedures

50

10

2003 2004 2005 2006

20

30

40

2000 Capsule EndoscopyIddan G et al.Nature 2000;405:417

Double-balloon Enteroscopeprovides therapeutic options

Yamamoto H et al. Gastrointest Endosc 2001;53:216-20

NBI

2007 Single Balloon Enteroscope making enteroscopy simpler?

OLYMPUS SIF Q180

NOTESNatural Orifice Translumenal Endoscopic Surgery

Kalloo AN et al.Flexible transgastric peritoneoscopy: a novel approachto diagnosis and therapeutic intervention in the peritoneal cavity.Gastrointest Endosc 2004;60:114-7

2004-2007Natural Orifice Translumenal Endoscopic Surgery (NOTES)

Animal experimentsKalloo AN et al. Flexible transgastric peritoneoscopy: a novel approach to diagnosis and therapeutic intervention in the peritoneal cavity. Gastrointest Endosc 2004;60:114-7Jagannath et al. Peroal transgastric endoscopic ligation of fallopian tubes with long-term survival in a porcine model. Gastrointest Endosc 2005;61:449-53Wagh MS et al. Endoscopic transgastric abdominal exploration and organ resection: initialexperience in a porcine model. Clin Gastroenterol Hepatol 2005;3:892-6Park PO et al. Experimental studies of transgastric gallbladder surgery: cholecystectomy and cholecystogastric anastomosis. Gastrointest Endosc 2005;61:601-6Kantsevoy SV et al. Endoscopic gastrojejunostomy with survival in a porcine model.Gastrointest Endosc 2005;62:287-92Pai RD et al. Transcolonic endoscopic cholecystectomy: a NOTES survival study in a porcine model. Gastrointest Endosc 2006;64:428-34Lima E et al. Transvesical endoscopic peritoneoscopy: a novel 5 mm port for intra-abdominal scarless surgery. J Urol 2006;176:802-5Sumiyama K et al. Transesophageal mediastinoscopy by submucosal endoscopy withmucosal flap safety valve technique. Gastrointest Endosc 2007;65:679-83

Source: Gastrointest Endosc 2005

NOTES: Creation of a gastroenterostomy

2004-2007Natural Orifice Translumenal Endoscopic Surgery (NOTES)

in human

Kalloo AN et al. Flexible transgastricperitoneoscopy: a novel approach to diagnosis and therapeutic intervention in the peritoneal cavity. Gastrointest Endosc 2004;60:114-7

Raddy N & Rao VG. Trangastric Appendectomy

Transvaginal endoscopic cholecystectomy (Strassburg, New York, Sao Paulo, ….)

Natural orifice

Zornig C et al. Endoscopy 2007;39:913-5

Hybrid transvaginal transumbilical NOTES

The dream of GI endoscopists

WWW.noscar.org.

Thank you !

President: Prof. Dr. N. SoehendraNOVEMBER 7-8, 2008

CONGRESSCENTRUMHAMBURGwww.endoclubnord.com