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Interventional Flexible Endoscopy
Figure 8.20 Snare polypectomy: (A) Polyp of the transverse colon; (B) the open snare
is placed over the lesion. When the loop is closed, electrical current causes transection and, simultaneously, coagulation of the base. Courtesy: Dr. J. Bachmann, Klinikum
rechts der Isar.
343
Figure 8.21 The principle of EMR. (A) Schematic description of the workflow. (a) Flat
intramucosal lesion; (b) injection of fluid into the submucosa; (ce) placement of the
snare, closure, and transection; (f) the resulting disk of removed mucosa will safely
heal in a few days. (B) The first step: Piercing the submucosa to create the fluid cushion. Courtesy: Prof. Dr. S. v. Delius, Klinikum rechts der Isar.
Endoscopic mucosal resection (EMR) is a safe technique, but it is
limited to mucosal lesions only. Frequently, it is not possible to retrieve
the specimen in one piece but in two or more fragments (piecemeal
resection) which is not desirable from the oncological point of view.
8.4.3.3 Endoscopic Submucosal Dissection
Some years ago, endoscopists developed a technique to perform even
deeper excisions: endoscopic submucosal dissection (
Fig. 8.22) [11].
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Biomedical Engineering in Gastrointestinal Surgery
Figure 8.22 (A) Endoscopic submucosal dissection. (a) Markers are coagulated into
the mucosa to define the area which has to be resected; (b) the area protrudes into
the lumen after submucosal injection is finished; (c) after the first incision with the
needle knife; (d) ESD in an advanced stage; (e) view on the muscle layer. Some vessels had to be clipped. (f) En bloc specimen with macroscopically free margins. (B)
The histological architecture of the intestinal wall. Right arrow: ESD; left arrow: EMR.
Courtesy: (A) Prof. Dr. S. v. Delius, Klinikum rechts der Isar, (B) M. Scholle.
Endoscopic submucosa dissection (ESD) is a step forward to better
oncological results, but it is more complication-prone than EMR. It is
becoming increasingly more popular since with specially designed instruments the management of complications (bleeding, perforation) could be
significantly improved
[12,13].
8.4.4 Endoscopic Interventions on the Bile Duct (ERCP)
Since 1973, ERCP completely lost the role of a diagnostic tool, since
magnetic resonance cholangiopancreatography (MRCP) and endoscopic
ultrasound examination (EUS) render comparable information and are
less risky.
However, ERCP became indispensable for the treatment
of pancreatobiliary disease (
Fig. 8.23). The range of ERCP-based
Interventional Flexible Endoscopy
Figure 8.23 A look onto the papilla with the duodenoscope (left side). Contrast
medium injected into the bile and pancreatic duct system (right side). The position
of the bile duct is indicated with the yellow arrow (white arrow in print). The blue
arrow (gray arrow in print) shows the pancreatic duct. Courtesy: Prof. Dr. C. Prinz,
HELIOS Universitätsklinikum Wuppertal.
345
Figure 8.24 (A) Multiple prepapillary bile duct stones; (B) the first cut with the
papillotome is accomplished. Note the first stone coming out. Courtesy: Prof. Dr. C.
Prinz, HELIOS Universitätsklinikum Wuppertal.
therapeutic approaches is wide: beginning with the removal of bile duct
stones (
Fig. 8.24), it includes stenting of benign and malignant narrowings
(stenosis) of the duct, photodynamic therapy, and the treatment of iatrogenic bile duct injuries.
346
Biomedical Engineering in Gastrointestinal Surgery
Figure 8.25 A selection of commercially available stents: (A) The unfolded stent:
shape after activation; (B) the process of stent positioning: on the delivery system,
the stent is drawn into length to reduce the outer diameter to a minimum. As soon
as it is positioned precisely in its future place, it is expanded to its maximum diameter (thus, losing length). Finally, the delivery system is removed and the GI transit
restored. All from MITI.
ERCP is performed with dedicated, side-viewing endoscopes with a
special lever to navigate the bile duct probes (see
Section 8.1.2: Side-
Viewing Duodenoscopes).
The full therapeutic potential of ERCP has certainly not yet been
fully exploited. BME is invited to provide even more advanced tools to
promote further this extremely elegant approach.
8.4.5 Gastrointestinal Stenting
Luminal obstruction in the GI tract always leads to dramatic consequences
for the patient. If untreated, it results in starvation if the obstruction is
located in the upper GI tract, and in sudden death following the ileus in
the lower GI tract. As an alternative to (palliative) surgery, interventional
endoscopy can now offer dilatation and stenting. Esophageal, duodenal,
bile duct, and colonic obstructions can be handled today with dedicated
stents
[14] (Fig. 8.25).
Stenting often provides immediate help (
cal situations, it is a valuable tool for palliation.
The use of stents is not only confined to the esophagus. Stents are
helpful as well in duodenal or colonic obstruction.
8.4.5.1 Bougienage and Balloon Dilatation
Narrowings of the GI lumen (stenoses) due to scar formation or tumorous lesions can be reopened and widened by the so-called “bougienage”
maneuver.
Fig. 8.26). In many oncologi-
Interventional Flexible Endoscopy
Figure 8.26 Stenting of an esophageal carcinoma: (A) A barium swallow of a subtotally occluding esophageal cancer. A thread-shaped channel of transit is left. The
patient is scarcely able to swallow small amounts of fluid. (B) After stent positioning,
the patient is immediately capable of normal food intake. Courtesy: Dr. A. Fingerle,
Klinikum rechts der Isar.
347
Figure 8.27 A bougie set (A) with guidewire (B). All from MITI.
Under radiographic control, a guidewire is positioned over the stenosis. Bougies of increasing diameter are then passed over the guidewire to
expand the internal diameter (
Fig. 8.27).
Frequently, a stent is finally positioned to secure the recanalization (see
Section 8.4.5: Gastrointestinal Stenting). In case of muscular obstruction,
bougienage is not helpful to eliminate the barrier. In these cases, pneumatic dilatation may be helpful.
8.4.6 Outlook
The breathtaking evolvement of interventional endoscopy will continue,
supported by technological developments, which are, among others, also
stimulated by NOTES (
Fig. 8.28).
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Biomedical Engineering in Gastrointestinal Surgery
Figure 8.28 Advanced interventional endoscopy: (A) The main bile duct is occluded
by a pancreatic tumor. The stricture cannot be overcome through the papilla of
Vater. To solve the problem, the dilated bile duct above the stricture is punctured
under EUS control from the duodenum. (B) A stent is positioned over a guidewire.
The obstruction is now deviated. Courtesy: Prof. Dr. A. Meining, University of Ulm.
It may be even assumed that the winning run of therapeutic flexible
endoscopy is just beginning—presuming innovative new tools
[15].
REFERENCES
[1] Vitale GC, Davis BR, Tran TC. The advancing art and science of endoscopy. Am J
Surg 2005;190(2):22833.
[2] Huang R, Yan H, Ren G, Pan Y, Zhang L, Liu Z, et al. Comparison of O-type
hybridknife to conventional knife in endoscopic submucosal dissection for gastric
mucosal lesions. Medicine (Baltimore) 2016;95(13):e3148.
[3] Lee BI, Kim BW, Kim HK, Choi H, Ji JS, Hwang SM, et al. Routine mucosal clo-
sure with a detachable snare and clips after endoscopic submucosal dissection for gastric epithelial neoplasms: a randomized controlled trial. Gut Liver 2011;5(4):4549.
[4] Matsuda K, Tajiri H. Tissue and fluid sampling. In: Classen M, Tytgat GNJ, Lightdale
CJ, editors. Gastroenterological endoscopy. 2nd ed. Stuttgart: Georg Thieme Verlag;
2010. p. 2039.
[5] Hayashi I, Yonezawa TM, Kuwabara T, Kudoh I. The study on staunch clip for the
treatment by endoscopy. Gastrointest Endosc 1975;17:92101.
[6] Mangiavillano B, Caruso A, Manta R, Di Mitri R, Arezzo A, Pagano N, et al. Over-
the-scope clips in the treatment of gastrointestinal tract iatrogenic perforation: a multicentre retrospective study and a classification of gastrointestinal tract perforations.
World J Gastrointest Surg 2016;8(4):31520.
[7] von Renteln D, Schmidt A, Vassiliou MC, Rudolph HU, Gieselmann M, Caca K.
Endoscopic closure of large colonic perforations using an over-the-scope clip: a randomized controlled porcine study. Endoscopy 2009;41(6):4816.
[8] Elmunzer BJ. Just clip it: endoscopic clipping in the 21st century. Am J Gastroenterol
2016;111(1):68.
349Interventional Flexible Endoscopy
[9] Mirante V, Bertani H, Grande G, Manno M, Caruso A, Mangiafico S, et al.
Effective endoscopic holmium laser lithotripsy in the treatment of a large impacted
gallstone in the duodenum. Endoscopy 2015;47(Suppl 1):UCTN: E485.
[10] Havanond C, Havanond P. Argon plasma coagulation therapy for acute non-variceal
upper gastrointestinal bleeding. Cochrane Database Syst Rev 2005;2: CD003791.
[11] Chung H, Dhumane P, Liu KH, Donatelli G, Dallemagne B, Marescaux J.
Endoscopic submucosal dissection with a novel traction method using a steerable
grasper: a feasibility study in a porcine model. Surg Innov 2014;21(1):510.
[12] Meining A, Schneider A, Roppenecker D, Lu¨th T. A new instrument for endo-
scopic submucosal dissection (with videos). Gastrointest Endosc 2013;77(4):6547.
[13] Nishiyama N, Mori H, Kobara H, Rafiq K, Fujihara S, Kobayashi M, et al. Efficacy
and safety of over-the-scope clip: including complications after endoscopic submucosal dissection. World J Gastroenterol 2013;19(18):275260.
[14] Dormann A, Meisner S, Verin N, Wenk Lang A. Self-expanding metal stents
for gastroduodenal malignancies: systematic review of their clinical effectiveness.
Endoscopy 2004;36(6):54350.
[15] Feussner H, Becker V, Bauer M, Kranzfelder M, Schirren R, Lu¨th T, et al.
Developments in flexible endoscopic surgery: a review. Clin Exp Gastroenterol
2015;8:3142.
CHAPTER 9
Combined LaparoscopicEndoscopic Procedures and
Natural Orifice Transluminal
Endoscopic Surgery (NOTES)
In the previous chapters it has been shown how successfully visceral
diseases can be treated either by conventional/laparoscopic surgery or
interventional endoscopy.
In the following chapter it is demonstrated how the strict borders
between both disciplines are gradually vanishing. A closer cooperation
opens up new dimensions of trauma reduction in the interventional treatment of gastrointestinal diseases (
Simultaneously to the development in laparoscopy, endoluminal flexible endoscopy changed from a diagnostic tool to an interventional therapeutic approach. Initially, this was regarded critically by surgeons, since
new competitors were suspected. The first major endoscopic therapeutic
intervention—endoscopic retrograde cholangiopancreatoscopy (ERCP)—
had been introduced into clinical care in 1973, which was well before the
era of minor access surgery. ERCP rapidly made the corresponding surgical technique—open bile duct exploration—obsolete. Benign and early
colonic tumors—formerly a domain of surgical resection—could now be
removed safely and fast by colonoscopic polypectomy in outpatients. The
clear distance between endoscopists and surgeons was gradually overcome
with the introduction of laparoscopy, in particular laparoscopic cholecystectomy. The option to remove bile duct stones by ERCP and papillotomy beforehand and to confine surgery to the resection of the gallbladder
was a precondition of the success of laparoscopic cholecystectomy, since
laparoscopic treatment of bile duct stones was still technically impossible
at that time. In addition, interventional gastroenterologists could help in
case of surgically induced bile duct lesions, which were not infrequent in
the beginning of laparoscopic surgery. Bile leakage could be sealed by
stents or str ictures could be dilated which helped to avoid revisional
Fig. 9.1).
Biomedical Engineering in Gastrointestinal Surgery. © 2017 Elsevier Inc.
All rights reserved.
351
352
Biomedical Engineering in Gastrointestinal Surgery
Figure 9.1 In the era of trauma reduction, the development of minimally invasive
surgery was accompanied by a rapid advance in interventional endoscopy.
Independently of each other, significant improvements could be achieved on
both sides. From MITI.
Figure 9.2 The bridge between internal medicine and surgery: Combined laparoscopic/endoscopic procedures. Surgeons and gastroenterologists cooperate at the
same workplace. From MITI.
surgery. The difficult relations between gastroenterologist and surgeon
were increasingly replaced with a cooperative attitude (
Fig. 9.2).
Beyond that, it has become clear during the last few years that both laparoscopy as well as flexible interventional endoscopy suffer from immanent
limitations. One important shortcoming of laparoscopic surgery is that no
information is available about the conditions beyond the surface. Precise
localization of endoparenchymatous or endoluminal lesions is impossible.
Interventional endoscopy is primarily confined to endoluminal activities. Additional shortcomings are the difficult hemostases in the case of
major bleeding or the management of wall perforation.
Soon, the idea came up to combine laparoscopy and endoscopy to
compensate for the shortcomings of either method.
By approaching the respective lesion from both sides, the potential of
both methods can be used synergetically. The first clinical reports
appeared in the early 1990s
[1,2].
353Combined Laparoscopic-Endoscopic Procedures and NOTES
The concept became rapidly popular all over the world and soon
became known as combined laparoscopic-endoscopic procedures (CLEP)
with the synonyms “hybrid visceral surgery” or “rendezvous surgery”
The next step is an even more intensive melange of surgical and flexible endoluminal endoscopy: natural orifice transluminal endoscopic surgery (NOTES). To enter the abdominal cavity, an opening through the
wall of the gastrointestinal tract is created and a flexible endoscope is used
to perform the surgical manipulation from within in order to avoid visible
scars. These two innovative approaches are the subjects of the next
sections.
[3,4].
9.1 COMBINED LAPAROSCOPIC-ENDOSCOPIC PROCEDURES (CLEP)
The idea is to perform both laparoscopic surgery and endoluminal endoscopy simultaneously during the respective intervention. This sounds easy,
but a number of technical preconditions have to be fulfilled before.
(Laparoscopic) surgery is performed in the surgical operating room,
whereas flexible gastrointestinal endoscopy is usually done in the endoscopy floor.
This type of surgery has to be located in the surgical OR, since the
endoscopy suite does not offer suitable conditions to carry out laparoscopic intervention. Accordingly, the surgical OR has to be equipped
with an endoluminal (flexible) endoscopy unit. Adequate education of
the surgical OR staff in the use of flexible endoscopy is indispensable.
The position of the laparoscopic team and of the endoscopist depends
upon the site of the lesion which has to be treated.
In case of upper GI tract surgery, esophagogastroduodenoscopy is
required. Colonoscopy is suitable to assist colonic surgery. Depending
upon the intervention, the endoscopist is located either at the head of the
patient or between the patient’s legs. Care has to be taken that both the
surgical team as well as the endoscopist have a good insight into not only
their own anatomical site but also into that of their respective partner
(
Fig. 9.3).
9.1.1 Indications
CLEP can be applied with lesions for which local excision is adequate,
but in which it cannot be achieved using peroral or transanal flexible
endoscopy due to the size and location of the lesion. Another indication