Becker's Hospital Review

68 Executive Briefing Sponsored by: I n recent years, the field of endoscopy has experienced incredible advances thanks to new cutting-edge procedures and technologies. These innovative and sophisticated endoscopic surgical techniques are designed to provide better patient outcomes and improved quality of life for individuals with a wide range of diagnoses. Only a limited number of medical centers, however, currently offer these treatments. Becker's Hospital Review recently spoke with Christopher C. Thompson, MD, Director of Endoscopy and Co-director of the Center for Weight Management and Wellness at Brigham and Women's Hospital in Boston, about flexible endoscopy and its role in endoscopic surgery, as well as critical supporting technologies like systems integration, high-resolution endoscopes and image enhancement. In addition to his roles at Brigham and Women's Hospital, Dr. Thompson is also Director of the Advanced Endoscopy Fellowship Program and a Professor at Harvard Medical School. NOTES: the movement that launched flexible endoscopy and surgical advances Many advanced endoscopic surgical procedures performed today originated from an innovation developed around 2005 called natural orifice transluminal endoscopic surgery, or NOTES. "It was an exciting time," Dr. Thompson said. "It looked like we could actually do transluminal surgery, meaning we could remove a gallbladder or appendix out through the mouth." The possibility of performing surgery with an endoscope led to an explosion of technological development. "Before the NOTES movement, we didn't have many accessories that went with an endoscope," Dr. Thompson said. "We had snares, injection needles and some clips, but not much else. Then we started seeing multitasking platforms where you could triangulate and dissect tissue more effectively. We had vessel sealing graspers, all sorts of dissection knives and devices that could create anastomoses endoscopically." The NOTES movement then disappeared, due to a variety of hurdles. Some were reimbursement related, but others related to the specialists performing these complex procedures. "Most surgeons didn't have the technical skill set to do complicated endoscopy and most endoscopists didn't have a surgical mindset and the ability to deal with intra-abdominal complications," Dr. Thompson said. "The technologies, however, have stayed around and found their way into a new type of endoscopic surgery that some people call flexible endoscopic surgery or natural orifice surgery." The endoscopic devices and technologies developed to support NOTES have made a whole new set of surgical procedures possible. These include peroral endoscopic myotomy, or POEM, procedures used to treat conditions like Zenker's diverticula, achalasia and gastroparesis. In POEM procedures, which are also referred to as third space endoscopy, surgeons make tunnels in the wall of the bowel between the muscle and the mucosa. "These procedures have largely replaced surgical diverticulectomy, Heller myotomy for achalasia and surgical pyloromyotomy for gastroparesis — and that's just the tip of the iceberg," Dr. Thompson said. "There are also several other procedures that we now perform to treat obesity with endoscopic suturing. We treat reflux with endoscopic anti- reflux procedures and the list goes on and on. As we look back, what really spurred these innovations nearly 15 years ago was the NOTES movement." Systems integration is the key to taking endoscopic surgery to the next level To perform advanced endoscopic surgery well, system integration is essential, according to Dr. Thompson. This technology makes it easy to work with a large monitor and pull information seamlessly from several different imaging platforms. "You see real-time fluoroscopy and endoscopy images next to one another," Dr. Thompson said. "Systems integration has made traditional endoscopic procedures safer and easier to perform." For example, patients with a stone in their bile duct or with more serious conditions like a hilar tumor in their bile duct are often treated with an endoscopic retrograde cholangiopancreatography (ERCP) procedure. To access one branch of the biliary system, clinicians have traditionally injected contrast, found the dilated system and then attempted to drain it. Unfortunately, little islands of contrast remain that can cause bile duct infections, potentially leading to serious complications including death. Systems integration has revolutionized this procedure. "With systems integration, you can pull up an MRCP; that is, an MRI that shows the bile duct. We can see that image right next to the ERCP image," Dr. Thompson said. "Rather than injecting a large amount of contrast, we run a wire into the biliary system that's dilated and insert a stent. We confirm that we're in the right spot by injecting a focal amount of contrast once we've achieved target access." Systems integration also enables clinicians to take endoscopic surgery to the next level. For instance, a handful of hospitals now perform endoscopic gastro-enteral anastomosis procedures on a regular basis to palliate pancreatic cancer. The technologies revolutionizing endoscopic surgery — Insights from Brigham and Women's Dr. Christopher Thompson

• Cover