Therapeutic endoscopy

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Therapeutic endoscopy
Other namesinterventional gastroenterology or interventional endoscopy or operative endoscopy

Therapeutic endoscopy is the medical term for an endoscopic procedure during which treatment is carried out via the endoscope. This contrasts with diagnostic endoscopy, where the aim of the procedure is purely to visualize a part of the gastrointestinal, respiratory or urinary tract in order to aid diagnosis. In practice, a procedure which starts as a diagnostic endoscopy may become a therapeutic endoscopy depending on the findings, such as in cases of upper gastrointestinal bleeding, or the finding of polyps during colonoscopy.

Contents

A number of different techniques have been developed to allow treatment to be carried out endoscopically, to treat disorders such as bleeding, strictures and polyps.

Types of endoscopic therapy

Endoscopic haemostasis

Endoscopic injection of bleeding peptic ulcers with adrenaline has been practised since the 1970s, [1] endoscopic heater probes have been used since the 1980s, [2] and Argon plasma coagulation has been used since the 1990s. More recently, adrenaline injection tends to be combined with either heater probe coagulation or argon plasma coagulation to minimize the chance of an ulcer rebleeding. The disadvantage of this treatment is a low risk of perforation of the gastric wall and a low risk of peritonitis. [3] Combined therapy may work better than epinephrine alone. However, there is no evidence that one kind of treatment is more effective than the other. [3]

Injection sclerotherapy

Injection sclerotherapy has been used to treat oesophageal varices since the 1960s. [4] A sheathed needle is passed through a channel in the endoscope, unsheathed and pushed into a varix. A sclerosing agent, such as ethanolamine or absolute alcohol, is then injected into the varix to cause scarring and constriction of the varix with the aim of obliterating the varix (or varices). This technique has now largely been superseded by variceal band ligation.[ citation needed ]

Sclerotherapy has also been used in the treatment of gastric varices since the late 1980s. [5] In this case Histoacryl glue (cyanoacrylate) is commonly used as the sclerosant. [6] This technique is favoured over band ligation because the position of the varices in the stomach, most often in the gastric fundus, makes the placing of bands very difficult.

Argon plasma coagulation

APC of bleeding oesophageal ulcer APC oesophagus.jpg
APC of bleeding oesophageal ulcer

Argon plasma coagulation (APC) has been used to provide tissue coagulation and haemostasis since the early part of the 1990s. [7] A stream of argon gas is passed through an endoscopic catheter; this is then ionized at the tip of the catheter by an electric current. The tip of the catheter is held close to the tissue to be treated, and the current arcs across to the tissue causing a superficial (2–3 mm) burn. The lack of contact between the catheter and the tissue stops the tendency of the catheter to stick to the tissue, reducing unwanted tissue damage. [8]

Its principal use is in providing haemostasis in gastrointestinal bleeding; angiodysplasia, GAVE, [9] bleeding malignant tumours and bleeding peptic ulcers can all be treated. Trials have also been carried out to assess its use in eradicating Barrett’s oesophagus, but have found that relapse is common. [10]

Dilatation

Pyloric stricture dilated with endoscopic balloon Pyloric dilatation.jpg
Pyloric stricture dilated with endoscopic balloon

Dilatation of benign oesophageal strictures using semi-rigid bougies existed long before the advent of flexible endoscopes. [11] Since that time oesophageal dilatation has been carried out using either bougies or endoscopic balloons, and can be used to treat benign oesophageal strictures and achalasia.[ citation needed ]

Initially, bougies were used to dilate benign strictures of the oesophagus. These could be passed alongside the endoscope, allowing visualisation of the bougie passing through the stricture, [12] but the technique of passing a guidewire through the stricture endoscopically, then removing the endoscope and passing the bougie over the guidewire was more commonly used. [13]

More recently, balloon dilatation of the oesophageal strictures has become more common. It is thought that this technique carries a lower complication rate than the use of bougies, and since endoscopy balloons are single use items there are no concerns about equipment sterilization. [11] In addition to oesophageal dilatation, endoscopic balloons can also be used to dilate pyloric strictures. [14]

Polypectomy

Polyp is identified, snare is passed over stalk and polyp is then removed Polypectomy.jpg
Polyp is identified, snare is passed over stalk and polyp is then removed

Endoscopic polypectomy has been carried out since the early 1970s by both endoscopic snare removal and fulguration of polyps with hot biopsy forceps. [15] [16]

Variceal banding

Oesophageal varices have been treated by band ligation since the late 1980s. [17]

Stenting

Expandable metal stent SEMS endo.jpg
Expandable metal stent

Expandable mesh stents can be deployed in the oesophagus at endoscopy, primarily in patients with inoperable oesophageal cancer which is causing dysphagia. [18]

Plastic stents can also be used to relieve obstruction of the common bile duct at ERCP. [19]

Percutaneous endoscopic gastrostomy

A method for inserting a feeding gastrostomy tube without the need for surgery was first described in 1980. [20] This endoscopic technique is of particular use as many patients who require feeding tubes (such as after patients with swallowing difficulties after a stroke) are at high risk for complications from anaesthesia and surgery; the endoscopic technique usually requires mild sedation only.[ citation needed ]

Foreign body removal

Foreign bodies commonly impact in the lower oesophagus, and removal of these by pushing them into the stomach has been practised since the Middle Ages. [11] Foreign body retrieval, using forceps and magnets, has been practised since the time of rigid oesophagoscopy and bronchoscopy.[ citation needed ]

Areas under development

Anti-reflux procedures

A number of techniques are being developed for the endoscopic treatment of gastro-oesophageal reflux disease as an alternative to laparoscopic Nissen fundoplication. [21]

Treatment of Barrett's oesophagus

Endoscopic circumferential radiofrequency ablation is being developed in an effort to obviate long-term endoscopic surveillance in patients with Barrett's oesophagus, and to reduce the risk of development of oesophageal carcinoma. Previous techniques, such as Argon plasma coagulation, have been unsuccessful because of incomplete removal of the Barrett's mucosa and therefore relapse of part of the treated area. [10] Newer techniques using circumferential radiofrequency ablation, which allows larger areas of the oesophagus to be treated at one time giving a more uniform area of treatment, are showing more promising short-term results. [22]

Transoral gastroplasty (TOGA procedure)

Early trials are under way to evaluate an endoscopic technique for gastric stapling, a type of bariatric surgery, which aims to induce long-term weight loss in morbidly obese patients. [23]

Related Research Articles

<span class="mw-page-title-main">Endoscopy</span> Procedure used in medicine to look inside the body

An endoscopy is a procedure used in medicine to look inside the body. The endoscopy procedure uses an endoscope to examine the interior of a hollow organ or cavity of the body. Unlike many other medical imaging techniques, endoscopes are inserted directly into the organ.

<span class="mw-page-title-main">Endoscope</span> Instrument to visually examine the interior of a hollow space

An endoscope is an inspection instrument composed of image sensor, optical lens, light source and mechanical device, which is used to look deep into the body by way of openings such as the mouth or anus. A typical endoscope applies several modern technologies including optics, ergonomics, precision mechanics, electronics, and software engineering. With an endoscope, it is possible to observe lesions that cannot be detected by X-ray, making it useful in medical diagnosis. Endoscopes use tubes which are only a few millimeters thick to transfer illumination in one direction and high-resolution images in real time in the other direction, resulting in minimally invasive surgeries. It is used to examine the internal organs like the throat or esophagus. Specialized instruments are named after their target organ. Examples include the cystoscope (bladder), nephroscope (kidney), bronchoscope (bronchus), arthroscope (joints) and colonoscope (colon), and laparoscope. They can be used to examine visually and diagnose, or assist in surgery such as an arthroscopy.

<span class="mw-page-title-main">Upper gastrointestinal bleeding</span> Medical condition

Upper gastrointestinal bleeding is gastrointestinal bleeding (hemorrhage) in the upper gastrointestinal tract, commonly defined as bleeding arising from the esophagus, stomach, or duodenum. Blood may be observed in vomit or in altered form as black stool. Depending on the amount of the blood loss, symptoms may include shock.

<span class="mw-page-title-main">Angiodysplasia</span> Medical condition

In medicine (gastroenterology), angiodysplasia is a small vascular malformation of the gut. It is a common cause of otherwise unexplained gastrointestinal bleeding and anemia. Lesions are often multiple, and frequently involve the cecum or ascending colon, although they can occur at other places. Treatment may be with colonoscopic interventions, angiography and embolization, medication, or occasionally surgery.

<span class="mw-page-title-main">Esophagogastroduodenoscopy</span> Diagnostic endoscopic procedure

Esophagogastroduodenoscopy (EGD) or oesophagogastroduodenoscopy (OGD), also called by various other names, is a diagnostic endoscopic procedure that visualizes the upper part of the gastrointestinal tract down to the duodenum. It is considered a minimally invasive procedure since it does not require an incision into one of the major body cavities and does not require any significant recovery after the procedure. However, a sore throat is common.

<span class="mw-page-title-main">Esophageal varices</span> Medical condition

Esophageal varices are extremely dilated sub-mucosal veins in the lower third of the esophagus. They are most often a consequence of portal hypertension, commonly due to cirrhosis. People with esophageal varices have a strong tendency to develop severe bleeding which left untreated can be fatal. Esophageal varices are typically diagnosed through an esophagogastroduodenoscopy.

<span class="mw-page-title-main">Gastrointestinal bleeding</span> Medical condition

Gastrointestinal bleeding, also called gastrointestinal hemorrhage (GIB), is all forms of bleeding in the gastrointestinal tract, from the mouth to the rectum. When there is significant blood loss over a short time, symptoms may include vomiting red blood, vomiting black blood, bloody stool, or black stool. Small amounts of bleeding over a long time may cause iron-deficiency anemia resulting in feeling tired or heart-related chest pain. Other symptoms may include abdominal pain, shortness of breath, pale skin, or passing out. Sometimes in those with small amounts of bleeding no symptoms may be present.

<span class="mw-page-title-main">Gastric varices</span> Medical condition

Gastric varices are dilated submucosal veins in the lining of the stomach, which can be a life-threatening cause of bleeding in the upper gastrointestinal tract. They are most commonly found in patients with portal hypertension, or elevated pressure in the portal vein system, which may be a complication of cirrhosis. Gastric varices may also be found in patients with thrombosis of the splenic vein, into which the short gastric veins that drain the fundus of the stomach flow. The latter may be a complication of acute pancreatitis, pancreatic cancer, or other abdominal tumours, as well as hepatitis C. Gastric varices and associated bleeding are a potential complication of schistosomiasis resulting from portal hypertension.

<span class="mw-page-title-main">Gastric antral vascular ectasia</span> Medical condition of the stomach

Gastric antral vascular ectasia (GAVE) is an uncommon cause of chronic gastrointestinal bleeding or iron deficiency anemia. The condition is associated with dilated small blood vessels in the pyloric antrum, which is a distal part of the stomach. The dilated vessels result in intestinal bleeding. It is also called watermelon stomach because streaky long red areas that are present in the stomach may resemble the markings on watermelon.

<span class="mw-page-title-main">Argon plasma coagulation</span> Medical procedure

Argon plasma coagulation (APC) is a medical endoscopic procedure used to control bleeding from certain lesions in the gastrointestinal tract. It is administered during esophagogastroduodenoscopy or colonoscopy.

<span class="mw-page-title-main">Hemosuccus pancreaticus</span> Medical condition

Hemosuccus pancreaticus is a rare cause of hemorrhage in the gastrointestinal tract. It is caused by a bleeding source in the pancreas, pancreatic duct, or structures adjacent to the pancreas, such as the splenic artery, that bleed into the pancreatic duct, which is connected with the bowel at the duodenum, the first part of the small intestine. Patients with hemosuccus may develop symptoms of gastrointestinal hemorrhage, such as blood in the stools, maroon stools, or melena, which is a dark, tarry stool caused by digestion of red blood cells. They may also develop abdominal pain. It is associated with pancreatitis, pancreatic cancer and aneurysms of the splenic artery. Hemosuccus may be identified with endoscopy (esophagogastroduodenoscopy), where fresh blood may be seen from the pancreatic duct. Alternatively, angiography may be used to inject the celiac axis to determine the blood vessel that is bleeding. This may also be used to treat hemosuccus, as embolization of the end vessel may terminate the hemorrhage. However, a distal pancreatectomy—surgery to remove of the tail of the pancreas—may be required to stop the hemorrhage.

<span class="mw-page-title-main">Self-expandable metallic stent</span>

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<span class="mw-page-title-main">Percutaneous transhepatic cholangiography</span> Medical imaging of the biliary tract

Percutaneous transhepatic cholangiography, percutaneous hepatic cholangiogram (PTHC) is a radiological technique used to visualize the anatomy of the biliary tract. A contrast medium is injected into a bile duct in the liver, after which X-rays are taken. It allows access to the biliary tree in cases where endoscopic retrograde cholangiopancreatography has been unsuccessful. Initially reported in 1937, the procedure became popular in 1952.

<span class="mw-page-title-main">Endoclip</span>

An endoclip is a metallic mechanical device used in endoscopy in order to close two mucosal surfaces without the need for surgery and suturing. Its function is similar to a suture in gross surgical applications, as it is used to join together two disjointed surfaces, but, can be applied through the channel of an endoscope under direct visualization. Endoclips have found use in treating gastrointestinal bleeding, in preventing bleeding after therapeutic procedures such as polypectomy, and in closing gastrointestinal perforations. Many forms of endoclips exist of different shapes and sizes, including two and three prong devices, which can be administered using single use and reloadable systems, and may or may not open and close to facilitate placement.

<span class="mw-page-title-main">Portal hypertensive gastropathy</span> Changes in the mucosa of the stomach in patients with portal hypertension

Portal hypertensive gastropathy refers to changes in the mucosa of the stomach in patients with portal hypertension; by far the most common cause of this is cirrhosis of the liver. These changes in the mucosa include friability of the mucosa and the presence of ectatic blood vessels at the surface. Patients with portal hypertensive gastropathy may experience bleeding from the stomach, which may uncommonly manifest itself in vomiting blood or melena; however, portal hypertension may cause several other more common sources of upper gastrointestinal bleeding, such as esophageal varices and gastric varices. On endoscopic evaluation of the stomach, this condition shows a characteristic mosaic or "snake-skin" appearance to the mucosa of the stomach.

<span class="mw-page-title-main">Esophageal food bolus obstruction</span> Medical condition

An esophageal food bolus obstruction is a medical emergency caused by the obstruction of the esophagus by an ingested foreign body.

<span class="mw-page-title-main">Butyl cyanoacrylate</span> Chemical compound

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<span class="mw-page-title-main">Nib Soehendra</span> German surgeon (born 1942)

Nib Soehendra is a German surgeon known for numerous contributions to the field of endoscopy and therapeutic endoscopy.

<span class="mw-page-title-main">Biliary endoscopic sphincterotomy</span> Use of endoscopy and fluoroscopy to treat and diagnose digestive issues.

Biliary endoscopic sphincterotomy is a procedure where the sphincter of Oddi and the segment of the common bile duct where it enters the duodenum are cannulated and then cut with a sphincterotome, a device that includes a wire which cuts with an electric current (electrocautery).

References

  1. ↑ Hirao M, Kobayashi T, Masuda K, Yamaguchi S, Noda K, Matsuura K, Naka H, Kawauchi H, Namiki M (October 1985). "Endoscopic local injection of hypertonic saline-epinephrine solution to arrest hemorrhage from the upper gastrointestinal tract". Gastrointestinal Endoscopy. 31 (5): 313–317. doi:10.1016/S0016-5107(85)72213-4. PMID   3876253.
  2. ↑ Sung JY, Chung SC, Lo KK, Leung JW (1988). "Heater-probe treatment of bleeding peptic ulcers". Surgical Endoscopy. 2 (4): 234–236. doi:10.1007/BF00705328. PMID   3071870. S2CID   26190281.
  3. 1 2 Vergara M, Bennett C, Calvet X, Gisbert JP (13 October 2014). Vergara M (ed.). "Epinephrine injection versus epinephrine injection and a second endoscopic method in high-risk bleeding ulcers". Cochrane Database of Systematic Reviews. 2014 (10): CD005584.pub3. doi:10.1002/14651858.CD005584.pub3. PMC   10714126 . PMID   25308912.
  4. ↑ Hunt PS, Johnston GW, Rodgers HW (7 December 2005). "The emergency management of bleeding oesophageal varices with sclerosing injections". British Journal of Surgery. 56 (4): 305–307. doi:10.1002/bjs.1800560416. PMID   4952481. S2CID   46306862.
  5. ↑ Sarin SK, Kumar A (October 1989). "Gastric varices: profile, classification, and management". Am. J. Gastroenterol. 84 (10): 1244–1249. PMID   2679046.
  6. ↑ Kind R, Guglielmi A, Rodella L, Lombardo F, Catalano F, Ruzzenente A, Borzellino G, Girlanda R, Leopardi F, Pratticò F, Cordiano C (July 2000). "Bucrylate Treatment of Bleeding Gastric Varices: 12 Years' Experience". Endoscopy. 32 (7): 512–519. doi:10.1055/s-2000-3817. PMID   10917182. S2CID   25835584.
  7. ↑ Grund KE, Storek D, Farin G (February 1994). "Endoscopic argon plasma coagulation (APC) first clinical experiences in flexible endoscopy". Endosc. Surg. Allied Technol. 2 (1): 42–46. ISSN   0942-6027. PMID   8081915.
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  9. ↑ Garcia N, Sanyal AJ (April 2001). "Portal hypertensive gastropathy and gastric antral vascular ectasia". Current Treatment Options in Gastroenterology. 4 (2): 163–171. doi:10.1007/s11938-001-0028-0. PMID   11469974. S2CID   179379.
  10. 1 2 Van Laethem J, Cremer M, Peny MO, Delhaye M, Devière J (1 December 1998). "Eradication of Barrett's mucosa with argon plasma coagulation and acid suppression: immediate and mid term results". Gut. 43 (6): 747–751. doi:10.1136/gut.43.6.747. PMC   1727342 . PMID   9824599.
  11. 1 2 3 Riley SA, Attwood SE (1 February 2004). "Guidelines on the use of oesophageal dilatation in clinical practice". Gut. 53 (90001): 1i–6. doi:10.1136/gut.53.suppl_1.i1. PMC   1867767 . PMID   14724139.
  12. ↑ Chung RS (1 July 1976). "Dilation of Esophageal Strictures: A New Technique Controlled by Fiberoptic Endoscopy". Archives of Surgery. 111 (7): 795–798. doi:10.1001/archsurg.1976.01360250071014. PMID   938225.
  13. ↑ Dupin B, Meric B, Dumon J (October 1987). "5 Techniques, results and complications of oesophageal dilatation". Baillière's Clinical Gastroenterology. 1 (4): 809–820. doi:10.1016/0950-3528(87)90020-0. PMID   3329544.
  14. ↑ Lindor KD, Ott BJ, Hughes RW (September 1985). "Balloon dilatation of upper digestive tract strictures". Gastroenterology. 89 (3): 545–548. doi:10.1016/0016-5085(85)90449-4. PMID   4018500.
  15. ↑ Williams C (November 1972). "Use of the long colonoscope for examination of the whole colon and for polypectomy". Proc. R. Soc. Med. 65 (11): 967. PMC   1644729 . PMID   4539317.
  16. ↑ Sivak MV, Sullivan BH (1973). "Gastroscopic polypectomy". Cleve Clin Q. 40 (3): 153–7. doi:10.3949/ccjm.40.3.153. PMID   4752356.
  17. ↑ Stiegmann GV, Goff JS, Sun JH, Wilborn S (February 1989). "Endoscopic elastic band ligation for active variceal hemorrhage". Am Surg. 55 (2): 124–8. PMID   2644882.
  18. ↑ Domschke W, Foerster EC, Matek W, Rödl W (May 1990). "Self-expanding mesh stent for esophageal cancer stenosis". Endoscopy . 22 (3): 134–6. doi:10.1055/s-2007-1012818. PMID   1694122. S2CID   7026676.
  19. ↑ Zimmon DS, Clemett AR (October 1982). "Endoscopic Stents and Drains in the Management of Pancreatic and Bile Duct Obstruction". Surgical Clinics of North America. 62 (5): 837–844. doi:10.1016/s0039-6109(16)42833-1. PMID   7123457.
  20. ↑ Gauderer MW, Ponsky JL, Izant RJ (December 1980). "Gastrostomy without laparotomy: A percutaneous endoscopic technique". Journal of Pediatric Surgery. 15 (6): 872–875. doi:10.1016/s0022-3468(80)80296-x. PMID   6780678.
  21. ↑ Chen D, Barber C, McLoughlin P, Thavaneswaran P, Jamieson GG, Maddern GJ (January 2009). "Systematic review of endoscopic treatments for gastro-oesophageal reflux disease". Br J Surg. 96 (2): 128–136. doi: 10.1002/bjs.6440 . PMID   19160349. S2CID   22481876.
  22. ↑ Eldaif SM, Lin E, Singh KA, Force SD, Miller DL (February 2009). "Radiofrequency Ablation of Barrett's Esophagus: Short-Term Results". Ann. Thorac. Surg. 87 (2): 405–411. doi:10.1016/j.athoracsur.2008.11.043. PMID   19161747.
  23. ↑ Moreno C, Closset J, Dugardeyn S, Baréa M, Mehdi A, Collignon L, Zalcman M, Baurain M, Le Moine O, Devière J (May 2008). "Transoral gastroplasty is safe, feasible, and induces significant weight loss in morbidly obese patients: results of the second human pilot study". Endoscopy . 40 (5): 406–413. doi:10.1055/s-2007-995748. ISSN   0013-726X. PMID   18459077. S2CID   260138542.
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