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Principles of flexible endoscopy for surgeons

Jeffrey M. Marks
Brian J. Dunkin

Principles of
Flexible Endoscopy
for Surgeons




Principles of Flexible Endoscopy for Surgeons

Jeffrey M. Marks

Brian J. Dunkin


Principles of Flexible
Endoscopy for Surgeons

Jeffrey M. Marks, M.D., F.A.C.S., F.A.S.G.E
Department of Surgery
Case Medical Center
University Hospitals
Cleveland, OH, USA

Brian J. Dunkin, M.D., F.A.C.S.
The Methodist Institute for Technology,
Innovation, and Education (MITIE)
The Methodist Hospital
Houston, TX, USA

ISBN 978-1-4614-6329-0
ISBN 978-1-4614-6330-6 (eBook)
DOI 10.1007/978-1-4614-6330-6
Springer New York Heidelberg Dordrecht London
Library of Congress Control Number: 2013935847
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I wish to thank my wife Gayle and children Andrea,
Jamie, and Jared for all of their endless support and
inspiration in my life and in my work.
Jeffrey M. Marks
I would like to thank my wife Annie and children
Joseph and Megan for sharing my dedication to
providing exceptional healthcare despite personal
sacrifices; and to my mentors—Drs. Jeffrey Ponsky
and Jeffrey Marks—for guiding me down the road
to a meaningful career.
Brian J. Dunkin


Why should there be a book devoted to techniques of flexible endoscopy? There are volumes of
books related to this subject. However, most all of these volumes deal with the relationship of
endoscopy to the practice of gastroenterology and do not address any special considerations
related to the management of surgical problems. Some gastroenterologists question the need for
surgeons to perform flexible endoscopy of the gastrointestinal tract at all! These individuals fail
to recognize the special questions surgeons must answer regarding the care of their patients and
the role of endoscopy in planning surgical intervention as well as treating complications. It is
important to note that the majority of endoscopic innovations have been developed by surgeons.
Drs. Marks and Dunkin are highly experienced and respected surgical endoscopists. They
have been innovators and pioneers of new methodology and have taught endoscopic skills to
hundreds of surgical residents and practicing surgeons throughout the world. In this volume, they
have brought together a team of outstanding surgical endoscopists to address basic endoscopic
principles and present new and developing technologies that directly impact the care of surgical
patients. Issues of management of surgical complications are addressed as well as alternatives to
traditional surgical techniques. Surgical endoscopy is a constantly evolving area of practice and
it is impossible for a single text to remain current for long. However, the combination of the basic
principles presented, along with instructional videos will help prepare the reader for new developments to come. This volume is an important addition to a surgeon’s library.
Cleveland, OH, USA

Jeffrey L. Ponsky, M.D., F.A.C.S.



Flexible endoscopy has become an increasingly integral part of surgery over the past several
decades as advancements in therapeutic endoscopic tools have augmented the care of complex
surgical patients. Preoperative endoscopic findings can provide information vital to a successful surgery. In addition, intra-operative endoscopy has gained increased popularity to augment
laparoscopic techniques that lack the tactile feedback readily available with open surgery.
Finally, many postoperative patients can now be managed with flexible endoscopic techniques,
avoiding challenging revisional surgery and a possible lengthy and complicated recovery. The
appropriate management of these patients, and resultant improved outcomes, requires a keen
understanding of recent endoscopic advancements, which are not routinely a core component
of surgical training programs.
There are numerous texts on flexible endoscopy, but they are uniformly created by and for
gastroenterologists, not surgeons. Surgeons have a unique understanding of the anatomy of the
GI tract and have specific needs regarding the information acquired from GI endoscopy in
order to plan for surgical interventions. Surgeons also realize the limitations of surgery for
managing complex complications and are particularly dedicated to pursuing endoscopic solutions to these difficult problems when warranted. As a result, this text, written entirely by
surgical endoscopists, presents a comprehensive overview of past, present, and future flexible
endoscopic techniques, with a focus on educating surgeons who may or may not already have
the skills to perform flexible endoscopy. In addition to the endoscopic management of surgical
issues, the role of surgery in the management of endoscopic complications is described. Basic
as well as advanced flexible endoscopic techniques are presented in both a didactic and visual
mode with extensive illustration, endoscopic images, and accompanying video clips.

Internet Access to Video Clip
The owner of this text will be able to access these video clips through Springer with the
following Internet link: http://www.springerimages.com/videos/978-1-4614-6329-0.
Cleveland, OH, USA
Houston, TX, USA

Jeffrey M. Marks
Brian J. Dunkin



The editors would like to thank the chapter authors for their excellent contribution to this text
and for their dedication to surgical endoscopy training.




A History of Flexible Gastrointestinal Endoscopy ................................................
Eric M. Pauli and Jeffrey L. Ponsky



Basic Components of Flexible Endoscopes ............................................................
Benjamin K. Poulose



Setup and Care of Endoscopes................................................................................
Ariel Eric Klevan and Jose Martinez



Pre-procedural Considerations ...............................................................................
Michael Larone Campbell, Jaime E. Sanchez, Sowsan Rasheid,
Evan K. Tummel, and Vic Velanovich



Intraprocedural Considerations .............................................................................
Jacqee M. Stuhldreher and Melissa S. Phillips



Post-procedural Considerations .............................................................................
Andrew K. Hadj and Mehrdad Nikfarjam



Endoscopic Tools/Techniques for Tissue Sampling ...............................................
Daniel von Renteln and Melina C. Vassiliou



Tools and Techniques for Gastrointestinal Hemostasis ........................................
Sajida Ahad and John D. Mellinger



Endoscopic Tools and Techniques for Tissue Removal and Ablation..................
Brian J. Dunkin



Endoscopic Tools and Techniques for Strictures and Stenoses ............................ 105
Eric M. Pauli and Jeffrey M. Marks

11Endoscopic Techniques for Enteral Access ................................................................ 119
Samuel Ibrahim, Kevin El-Hayek, and Bipan Chand

Endoscopic Tools and Techniques for Fistula and Leaks ..................................... 129
Ahmed Sharata and Lee L. Swanstrom


Endoscopic Considerations in Morbid Obesity..................................................... 139
Vimal K. Narula, Dean J. Mikami, and Jeffrey W. Hazey


Endoscopic Considerations in Gastroesophageal Reflux Disease ........................ 157
W. Scott Melvin and Jeffrey L. Eakin


Intraoperative Endoscopy ....................................................................................... 167
Robert D. Fanelli


Techniques of Upper Endoscopy............................................................................. 183
Thadeus L. Trus





Techniques and Tips for Lower Endoscopy ........................................................... 191
Joanne Favuzza and Conor Delaney


Techniques of Office-Based Endoscopy: Unsedated
Transnasal Endoscopy ............................................................................................. 201
Toshitaka Hoppo and Blair A. Jobe


Techniques of Endoscopic Retrograde Cholangiopancreatography ................... 215
Jonathan Pearl


Management of Endoscopic Complications........................................................... 227
Jeremy Warren, David Hardy, and Bruce MacFadyen Jr.


Photodocumentation of Endoscopic Findings ....................................................... 251
Bruce Schirmer and Lane Ritter


Future of Endoscopy ................................................................................................ 261
Eric Hungness and Ezra Teitelbaum

Index .................................................................................................................................. 275


Sajida Ahad, M.D. Department of Surgery, Southern Illinois University School of Medicine,
Springfield, IL, USA
Michael Larone Campbell, M.D. Department of Surgery, University of South Florida,
Tampa, FL, USA
Bipan Chand, M.D., F.A.C.S. Associate Professor of Surgery, Minimally Invasive Surgery,
Loyola University, Maywood, IL, USA
Conor Delaney, M.D., Ph.D. Division of Colorectal Surgery, University Hospitals Case
Medical Center, Cleveland, OH, USA
Brian J. Dunkin, M.D., F.A.C.S. Section of Endoscopic Surgery, MITIESM (The Methodist
Institute for Technology, Innovation, and Education), The Methodist Hospital, Houston, TX, USA
Jeffrey L. Eakin, M.D., B.A. Department of General Surgery Center for Minimally Invasive
Surgery, The Ohio State University Medical Center, Columbus, OH, USA
Kevin El-Hayek, M.D. Surgical Endoscopy, Department of Bariatric and Metabolic Institute,
Cleveland Clinic Hospital, Cleveland, OH, USA
Robert D. Fanelli, M.D., F.A.C.S., F.A.S.G.E. Chief-Minimally Invasive Surgery and
Surgical Endoscopy, Department of Surgery, The Guthrie Clinic Ltd., One Guthrie Square,
Sayre, PA, USA
Joanne Favuzza, D.O. Division of Colorectal Surgery, University Hospitals Case Medical
Center, Cleveland, OH, USA
Andrew K. Hadj, M.D., B.S. Department of Surgery, University of Melbourne, Austin
Health, Melbourne, VIC, Australia
David Hardy, M.D. Department of Surgery, Augusta State University and Georgia Health
Sciences University, Augusta, GA, USA
Jeffrey W. Hazey, M.D., F.A.C.S. Division of General and Gastrointestinal Surgery,
Department of Surgery, The Ohio State University, Columbus, OH, USA
Toshitaka Hoppo, M.D., Ph.D. Department of Surgery, Institute for the Treatment of
Esohageal & Thoracic Disease, West Penn Allegheny Health System, Pittsbrugh, PA, USA
Eric Hungness, M.D. Department of Surgery, Northwestern University, Chicago, IL, USA
Samuel Ibrahim, M.D. Department of General Surgery, Cleveland Clinic Foundation,
Cleveland, OH, USA
Blair A. Jobe, M.D., F.A.C.S. Department of Surgery, Institute for the Treatment of Esohageal
& Thoracic Disease, West Penn Allegheny Health System, Pittsbrugh, PA, USA
Ariel Eric Klevan, M.D., F.R.C.S.C. Department of Surgery, Jackson Memorial Hospital,
University of Miami Hospital, Miami, FL, USA


Bruce MacFadyen Jr., M.D. Department of Surgery, Medical College of Georgia, Augusta,
Jeffrey M. Marks, M.D., F.A.C.S., F.A.S.G.E. Department of Surgery, University Hospitals,
Case Medical Center, Cleveland, OH, USA
Jose Martinez, M.D., F.A.C.S. Department of Surgery, Miller School of Medicine, University
of Miami, Miami, FL, USA
John D. Mellinger, M.D., F.A.C.S. Department of Surgery, Southern Illinois University
School of Medicine, Springfield, IL, USA
W. Scott Melvin, M.D. Department of General Surgery, The Ohio State University Hospital,
Columbus, OH, USA
Dean J. Mikami, M.D., F.A.C.S. Department of Gastrointestinal Surgery, Wexner Medical
Center at the Ohio State University, Columbus, OH, USA
Vimal K. Narula, M.D., F.A.C.S. Division of General and Gastrointestinal Surgery,
Department of Surgery, The Ohio State University, Columbus, OH, USA
Mehrdad Nikfarjam, M.D., Ph.D., F.R.A.C.S. Department of Surgery, University of
Melbourne, Austin Health, Melbourne, Australia
Eric M. Pauli, M.D. Department of Surgery, Penn State Hershey Medical Center, Hershey,
Jonathan Pearl, M.D. Department of Surgery, Uniformed Services University, Bethesda,
Melissa S. Phillips, M.D. Department of Surgery, University of Tennessee Graduate School
of Medicine, Knoxville, TN, USA
Jeffrey L. Ponsky, M.D. Department of Surgery, CWRU, University Hospitals Case Medical
Center, Cleveland, OH, USA
Benjamin K. Poulose, M.D., M.P.H. Department of Surgery, Vanderbilt University Medical
Center, Nashville, TN, USA
Sowsan Rasheid, M.D. Department of Surgery—Colorectal, University of South Florida,
Tampa, FL, USA
Lane Ritter, M.D. Department of Surgery, University of Virginia Health System,
Charlottesville, VA, USA
Jaime E. Sanchez, M.D., M.S.P.H. Department of Surgery, Division of Colon and Rectal Surgery,
University of South Florida, Tampa, FL, USA
Bruce Schirmer, M.D. Department of Surgery, University of Virginia Health System,
Charlottesville, VA, USA
Ahmed Sharata, M.D. Department of General and Minimally Invasive Surgery, Oregon
Clinic, Portland, OR, USA
Jacqee M. Stuhldreher, M.D. Department of General Surgery, University Hospitals Case
Medical Center, Cleveland, OH, USA
Lee L. Swanstrom, M.D. Division of Gastrointestinal and Minimally Invasive Surgery,
The Oregon Clinic, Oregon Health and Sciences University, Portland, OR, USA
Ezra Teitelbaum, M.D. Department of Surgery, Northwestern University, Chicago, IL,




Thadeus L. Trus, M.D. Department of Surgery, Dartmouth-Hitchcock Medical Center,
Lebanon, NH, USA
Evan K. Tummel, M.D. Division of Colon and Rectal Surgery, University of South Florida,
Tampa, FL, USA
Melina C. Vassiliou, M.D., M. Ed. Department of Surgery, Montreal General Hospital,
McGill University, Montreal, QC, Canada
Vic Velanovich, M.D. Department of Surgery, University of South Florida, Tampa, FL,
Daniel von Renteln, M.D. Department of Interdisciplinary Endoscopy, University Hospital,
University Medical Center Hamburg-Eppendorf, Hamburg, Germany
Jeremy Warren, M.D. Department of Surgery, Augusta State University and Georgia Health
Sciences University, Augusta, GA, USA


A History of Flexible Gastrointestinal
Eric M. Pauli and Jeffrey L. Ponsky

For millennia, physicians have endeavored to view the interior of the gastrointestinal tract in order to diagnose and treat
disease. Greek, Roman, and Egyptian scholars are all known
to have created specula with which body orifices were
viewed. Early endoscopes of the nineteenth century were
rigid instruments with large lumens that lacked lens systems
and depended upon light provided by candle or flame. Later
rigid instruments employed lens assemblies and small bulbs
at the tip of the instrument which generated intense heat.
Early in the twentieth century, instruments with semiflexible
rubber tips were developed to facilitate passage of the endoscope into the esophagus. In the mid-twentieth century, the
development of fiber-optic technology permitted the evolution of flexible endoscopes that transmitted “cold light” from
an outside source. Light was carried by a fiber-optic bundle
from the external source, through the endoscope, to the interior of the viscus being viewed. As light returned through the
endoscope, each fiber carried a parcel of the image.
It was from these early fiber-optic endoscope systems that
the modern era of flexible gastrointestinal endoscopy has
evolved. Throughout this evolution, surgeons have played an
unparalleled role in the development of diagnostic and therapeutic modalities. This chapter provides an overview of the
history of flexible gastrointestinal endoscopy with particular
emphasis on the role of surgeons (frequently in multidisciplinary collaboration) in the development of the techniques
outlined in this text.

E.M. Pauli, M.D.
Department of Surgery, Penn State Hershey Medical Center,
Hershey, PA, USA
e-mail: epauli@hmc.psu.edu
J.L. Ponsky, M.D. (*)
Department of Surgery, CWRU, University Hospitals Case Medical
Center, Cleveland, OH, USA
e-mail: jeffrey.ponsky@uhhospitals.org

Rigid and Semiflexible Gastrointestinal
The first technically successful attempt at rigid endoscopy
was performed by Philipp Bozzini in 1805 when the German
physician used his lichtleiter (German for “light conductor”)
to direct candle light into the human body through metal casings (Fig. 1.1a) [1]. Tin tubes of various sizes were developed for the nose, esophagus, bladder, and rectum (Fig. 1.1b).
Technical advancement in light sources saw the replacement
of a candle with a mixture of turpentine and alcohol (to
increase illumination and decrease smoke) and ultimately by
wire/filament light sources [2–4]. Maximilian Carl-Friedrich
Nitze, a general practitioner with an interest in the urinary
bladder, developed a working cystoscope with an internal,
filamentous light source and lenses to magnify the image [3, 5].
He later developed a cystoscope capable of holding glass
plates with light-sensitive coating capable of producing permanent photographs of the cystoscopic image [6].
In 1880, Johann Mikulicz-Radecki (Fig. 1.2), a PolishAustrian surgeon working for Theodore Billroth, produced the
first gastroscope, which he based off of Nitze’s cystoscope.
His modifications included mirrors to create a 30° angled field
of view and a miniature version of Thomas Edison’s electric
incandescent globe as a light source [7]. He later added a
separate air channel to his 650 mm long, 13 mm diameter
instrument. With it, Mikulicz was the first to describe the
endoscopic view of a gastric carcinoma and performed the
endoscopic removal of a bone obstructing the esophagus by
pushing it into the stomach with his instrument [8, 9].
Examination of the lower GI tract occurred along parallel
lines. Howard Kelly, professor of Obstetrics and Gynecology,
Halsted-trained surgeon and one of the “Founding Four” of
Johns Hopkins Hospital, was the first to describe rigid sigmoidoscopy. In 1895, he used his 350 mm long self-designed
instrument to view the distal colon and rectum by reflecting
electric light from a conventional bulb of a head-mounted
mirror (Fig. 1.3).

J.M. Marks and B.J. Dunkin (eds.), Principles of Flexible Endoscopy for Surgeons,
DOI 10.1007/978-1-4614-6330-6_1, © Springer Science+Business Media New York 2013



E.M. Pauli and J.L. Ponsky

Fig. 1.1 Bozzini’s lichtleiter (a) assembled with speculum attached and (b) unassembled, and with a variety of the available specula

Fig. 1.2 Johann Mikulicz-Radecki (1850–1905) was an innovator
in many areas of surgery, including producing the first gastroscope

In 1911, Henry Elsner introduced a two-part gastroscope.
The rigid outer cannula allowed passage of the flexible rubber-tipped inner optical component. This two-part system
and flexible tip greatly reduced the perforation rate of gastroscopy. It was the Elsner gastroscope with which Rudolph
Schindler, a medical gastroenterologist, pathologist, and
army surgeon, pioneered the field of gastroscopy, publishing
his findings in Lehrbuch und Atlas der Gasteroskopie
(Textbook and Atlas of Gastroscopy) in 1923 [10]. He later
modified the Elsner scope to include a separate channel to
flush the lens of secretions and ultimately create, with Wolf,
a semiflexible gastroscope [11]. The proximal and distal

Fig. 1.3 Howard Kelly (1858–1943) performed sigmoidoscopy by
reflecting light from a bulb of a head-mounted mirror and down a rigid

rigid segments of this device were connected by a passively
flexible segment that used a series of prisms to transmit the
image through the gentle curve (Fig. 1.4). The maximum
bending angle for this endoscope was around 30–34°, after
which, image transmission failed [3]. This Wolf–Schindler
gastroscope was adopted as the endoscope worldwide due to
its greatly improved safety and efficacy.
In April 1933, Edward Benedict, a general surgeon, and
Chester Jones, an endoscopist, described the first American trials using the Wolf–Schindler gastroscope at the Massachusetts


A History of Flexible Gastrointestinal Endoscopy


Fig. 1.4 Wolf–Schindler gastroscope with flexible distal segment and
rigid proximal segment

General Hospital [12]. So enamored was Benedict by his initial
experience with gastroscopy, that he gave up his general surgical practice to focus on laparoscopy and endoscopy. In 1948,
Benedict was the first to develop a functional, operative gastroscope, including the development of biopsy forceps [13]. By
widening the diameter of the Wolf–Schindler gastroscope from
11 to 14 mm, he was able to add a suction channel that permitted the passage of his biopsy instrument. This permitted direct
sampling of endoscopically identified lesions for histological
analysis [14].
Despite these progressive improvements, however, the
limitations of lens systems, rigid or semirigid instrumentation, internal placement of the light source, as well as high
degrees of light loss (more than 90 %) all combined to limit
the reach and visual capabilities of these early endoscope
systems [15]. While semiflexible instruments with biopsy
capabilities were functional for many clinical purposes, the
development of totally flexible endoscopic tools would revolutionize the diagnostic and therapeutic capabilities of

Diagnostic Flexible Gastrointestinal Endoscopy
The use of bundled, pure glass (silica) fibers as a conduit for
light and optical images for medical purposes was described
by Heinrich Lamm, a gynecologist, in late 1930. Lamm
demonstrated that the principle of total internal reflection of
light allowed image transduction even when the fiber-optic
bundles were bent or flexed. Unfortunately, the fibers used
by Lamm allow a high degree of light loss and image degradation. It was not until 1954 when Harold Hopkins, a
Professor of Applied Physics at Imperial College in London,
and his student, Narinder Kapany, developed a flexible fiberoptic system with low light and image loss [16]. The Hopkins
system utilized glass rods coated in a reflective cladding as
well as two separate fiber bundles [12]. The “coherent” bundle contained fibers whose relative positions in the input and
output ends are the same; this permitted pure image transmission (Fig. 1.5). The “incoherent” bundle fibers were randomly arranged but permitted high-intensity light
transmission through the length of the bundle.
Utilizing these new fiber-optic bundles, Basil Hirschowitz,
a gastroenterologist in fellowship training at the University
of Michigan, developed a prototype flexible gastroscope with

Fig. 1.5 Schematic of a coherent fiber-optic bundle. The preserved
relative fiber positions in the input and output ends are the same, permitting pure image transmission

his colleagues in the physics department. In early 1957,
Hirschowitz first utilized the gastroscope on himself and several days later performed the first fiber-optic gastroscopy on
a patient (Fig. 1.6) [17]. His gastroscope was a 92 cm long,
11 mm wide instrument with coherent fiber-optic bundles
that transmitted images illuminated by a light at the distal end.
This device was a side-viewing instrument with a single air/
suction/irrigation channel and an adjustable lens on the handpiece to allow variable focus. The advantage of the flexible
endoscope was almost immediately evident, as in nearly
50 % of patients, the duodenum was successfully examined
with the endoscope [18]. The Hirschowitz gastroduodenal
fiberscope was introduced to the market in late 1960 by the
American Cystoscope Makers, Inc (ACMI) and quickly
gained favor [19, 20].
Modifications on the Hirschowitz endoscope occurred
rapidly over the next several years as manufacturers developed progressively longer, forward-viewing devices with
greater tip control. The addition of a second incoherent
fiber-optic bundle allowed light to be transmitted down the
endoscope shaft and permitted the use of an external light
The idea for this external light source is credited to George
Berci, a surgeon working in Los Angeles, California [5]. He
discussed the idea with Karl Storz, the German instrument
manufacturer who produced the endoscopes in collaboration
with Hopkins [21–23]. This new endoscope transmitted the
light from an external 150 W light bulb down the shaft of the
device to provide internal illumination. While this was a vast
improvement over internal light bulbs at the distal instrument tip, the degree of illumination was still considered
insufficient. In 1976, Berci introduced the miniature, highintensity (300 W), explosion-proof xenon arc globe as the
light source for an endoscope, the same bulb currently in use
by every manufacturer of endoscopic instruments [23, 24].
By 1971, a 105 cm long “panendoscope” was available
from both Olympus and ACMI. These end-viewing devices
had an external light source, four-way steerable tip control


E.M. Pauli and J.L. Ponsky

Fig. 1.6 Basil Hirschowitz
(1925–2013) performing the first
fiber-optic gastroscopy on a patient

Fig. 1.7 Panendoscope, with external light source, lens irrigation
capabilities, four-direction tip control, and suction

capable of 180° retroflexion, lens washing capabilities, and a
biopsy channel (Fig. 1.7). These devices made evaluation of
the duodenum during upper endoscopy a matter of routine.
Recognizing the opportunity that duodenal access represented, William S. McCune, a surgeon at George Washington

University in Washington D.C., performed the first endoscopic retrograde cholangio-pancreatography (ERCP) in
1968 [25]. Utilizing an endoscope with both forward- and
side-viewing capabilities, McCune and colleagues nonselectively cannulated the ampulla of Vater with a catheter
passed through a guide tube taped onto the shaft of the instrument. Radio-opaque contrast solution was injected, permitting evaluation of the pancreatic and common bile duct.
The Japanese, under the leadership of Itaru Oi, further
developed this technique and demonstrated its practicality.
Using a Machida fiberduodenoscope (FDS-LB) capable of
60° distal tip rotation, Oi and colleagues visualized the papilla
in 94 % of cases and cannulated it in 41 patients [26, 27].
His methods were subsequently popularized and taught to
thousands of endoscopists by Drs. Peter Cotton, Steve Silvis,
Jack Vennes, and Joseph Geenen [28–34].
Soon after the development of a forward-viewing flexible
gastroscope, investigators turned modified versions of the
devices to examination of the colon and rectum. Robert
Turell, a surgeon at The Mount Sinai Hospital in New York,
first described flexible colonoscopy, but ultimately concluded that his instrument was not yet fit for routine clinical
application [35, 36]. Further manufacturer developments
improved the sigmoidoscope. Bergein Overholt, while a
gastroenterology fellow at New York Hospital-Cornell
University Medical Center, New York, pursued and popularized flexible diagnostic sigmoidoscopy [37, 38]. He later
became instrumental in the development of dedicated
colonoscopic length endoscopes.
By 1970, both ACMI and Olympus were producing
flexible colonoscopes designed to permit cecal intubation.
The primary impediment to this now routine task was a lack


A History of Flexible Gastrointestinal Endoscopy

Fig. 1.8 Hiromi Shinya performing colonoscopic exam. Note the lead
apron; fluoroscopy was heavily utilized to develop modern methods of
navigation through the colon

of standardized technique to advance the endoscope beyond
the more distal colon. While many notable physicians contributed to the development of these techniques (including
Jerome Wayne, Christopher Williams, and Bergein Overholt),
it was Hiromi Shinya, a Japanese born, American trained surgeon, who developed many of the colonoscopic techniques
that made the technique popular in the United States (Fig. 1.8)
[5]. Shinya, with William Wolff at Beth Israel Medical Center
in New York, began his colonoscopy work in 1967 with an
Olympus-EF gastroscope. He ultimately transitioned to a
dedicated 186 cm long colonoscope (Olympus CF-LB) [39].
With this endoscope and his technical expertise, Shinya
and Wolff reported ever-improving cecal intubation rates in
their early experience of 241 patients and established the
advantage of endoscopy over barium enema [40, 41]. Shinya
also adapted the wire loop method of polypectomy to the
endoscope. In September 1969 he performed the first colonoscopic snare polypectomy on a 1.5 cm pedunculated proximal sigmoid polyp [42]. Within the next 3 years he and Wolff
performed hundreds of snare polypectomies with minimal
morbidity and no mortality, sparing patients open surgical
resection of these lesions [43, 44].

Therapeutic Flexible Gastrointestinal
Shinya and Wolff ushered in the era of therapeutic colonoscopy by making snare polypectomy the new standard of care.
For polyps not amenable to snare resection, marking of


lesions discovered at colonoscopy became necessary and a
technique of endoscopic injection of India ink was developed
[45]. Jeffrey Ponsky, at the time a surgery resident at
University Hospitals of Cleveland, Ohio, and James King, a
gastroenterologist in Canton, Ohio, described the use of
1–2 ml of India ink to create a surgically identifiable black
mark on the antimesenteric border of the colon near the
lesion to be resected. Within short order, additional colonoscopic interventions were described, including foreign body
removal, suture excision, and the application of sclerosing
agents and electrocautery to bleeding lesions [46].
Many of the techniques used for therapeutic colonoscopy
had initially been developed and described for diseases of the
upper gastrointestinal tract, most notably control of gastrointestinal hemorrhage. Diagnostic upper endoscopy was
already having profound impact on the treatment algorithms
and clinical outcomes for upper gastrointestinal bleeding
(UGIB). Choichi Sugawa, a surgeon at Wayne State
University in Detroit, Michigan, and his colleagues completed upper endoscopy in 41 of 42 patients with UGIB, correctly identifying the source of bleeding in 95 % of these
patients [47]. Hellers and Ihre, surgeons working in
Stockholm, Sweden, evaluated their UGIB patients in the
immediate pre- and post-endoscopy era and saw failure to
reach a diagnosis fall from almost 40 to 5–7 % [48]. Operation
rates increased (due to more accurate diagnosis of the bleeding site), transfusion requirements decreased, and mortality
in both the operated (47 % vs. 11 %) and non-operated (17 %
vs. 8 %) population fell dramatically.
Recognizing the potential benefits of endoscopic intervention for UGIB, surgeons and gastroenterologists alike
rapidly developed methods to control endoscopically
identified hemorrhage. C Roger Youmans, Jr, a surgeon at
the University of Texas in Galveston, first described endoscopic management of gastric hemorrhage [49]. Passing a
rigid cystoscope through a preexisting gastrostomy site,
Youmans utilized the continual flow of irrigation fluid to
identify the bleeding site, which was subsequently fulgurated
(Fig. 1.9) [50].
Methods of endoscopic cautery through a flexible gastroscope were subsequently described [51, 52]. Sugawa’s experience in diagnostic gastroscopy for UGIB transitioned to
therapeutic endeavors. In 1975, he reported clinical success
in managing six patients with UGIB from a variety of causes
by using electrocoagulation with a Cameron-Miller flexible
suction coagulator electrode (Fig. 1.10) [53]. John Papp, a
gastroenterologist at Michigan State University, and Walter
Gaisford, a surgeon at LDS Hospital in Salt Lake City, Utah,
subsequently described similarly high success rates (92–
95 %) in series of 245 and 160 patients with UGIB, respectively [54–56].
In the following years, additional therapies for UGIB
were developed. Working at the University of Hamburg,


Fig. 1.9 Electrocautery of a bleeding gastric ulcer using a rigid cystoscope passed through a preexisting gastrostomy site. With permission
from [49]. Copyright 1970 American Medical Association

E.M. Pauli and J.L. Ponsky

(dilute epinephrine) were soon applied to bleeding lesions
throughout the GI tract [58]. In 1985, Masanori Hirao and
his surgical colleagues at Kin-Ikyo Chuo Hospital in Sapporo,
Japan, described the endoscopic injection of a mixture of
hypertonic saline and dilute epinephrine solution to promote
hemostasis and vascular sclerosis [59]. Three years later,
Greg van Steigman, a surgeon, and John Goff, a gastroenterologist, at the University of Colorado in Denver, described
132 endoscopic variceal band ligations in 44 patients with no
major complications (perforation, secondary bleeding) and
no treatment failures [60]. This markedly decreased the need
for portal systemic shunting for hemorrhage.
Diagnostic and therapeutic methods for UGIB were soon
applied to the lower GI tract and, in similar fashion, polypectomy methods from the colon were applied to the stomach
[61–63]. Endoscopic methods continued to replace traditional open surgical procedures. In 1979, Drs. Michael
Gauderer and Jeffrey Ponsky performed the first percutaneous endoscopic gastrostomy (PEG) [64]. This was first
published and presented in 1980 and soon was the most
widely practiced approach for feeding access. This was soon
followed by similar approaches to the jejunum for long-term
enteral access in patients who could not tolerate gastric
feedings [65]. Around the same time frame, descriptions of
the use of plastic endoprosthesis for the relief of malignant
obstructions and balloon dilation of benign stricture/obstructions were recorded [66–70].
A therapeutic dimension was added to ERCP in 1974 by
Drs. Kawai in Japan and Classen in Germany who independently developed methods of endoscopic sphincterotomy to
permit extraction of common bile duct stones [71–74]. Soon
after, endoscopic biliary stenting for strictures and malignancy was developed by Soehendra [75]. Subsequent
advances in ERCP have included expandable metal stenting,
cholangioscopy, excision of ampullary masses, pancreatoscopy, and pancreatic duct stenting, all of which were made
possible by the methods defined by these early pioneers.

Video Endoscopy and the Era of Advanced
Endoscopic Techniques

Fig. 1.10 Management of a bleeding gastric ulcer using a CameronMiller flexible suction coagulator electrode (arrow) passed through a
flexible gastroscope. With permission from [53]. Copyright 1975
American Medical Association

German surgeon Nib Soehendra described the use of a sclerosing agent (1.5 % solution of Aethoxysklerol®) to induce
hemostasis in bleeding gastric ulcers [57]. Additional sclerosing agents (like 95 % ethanol) and vasoconstrictive agents

Conventional rigid and fiber-optic endoscopy limited the
practitioner in a number of ways that suppressed further
advances in therapeutic techniques. The use of a single optical axis meant that the endoscopist utilized only one eye,
which was held close to the controls of the device. This was
an uncomfortable position, and one which limited the teaching ability as well as the ability of the assistants to visualize
the actual endoscopic procedure (and to subsequently provide actual “assistance” in the procedure). Image documentation of the procedures was also difficult, as the endoscopist
could not simultaneously observe the image and capture it on


A History of Flexible Gastrointestinal Endoscopy

film when the camera was attached to the eye piece of the
endoscope. Video technology was the solution to all of these
The first report of video endoscopy occurred in France
with 1956 when a regular video camera was attached to the
end of a rigid gastroscope to project black and white images
onto a television screen. Because of the size and expense of
early video equipment, this endeavor required transporting
the patient to a video studio. Refinement in video equipment
in the 1960s and 1970s made these efforts easier, but clinical
enthusiasm was never great [3].
In 1984, Welch Allyn removed the coherent fiber-optic
image bundle in a colonoscope and replaced it with electrical
wires attached to a charge-coupled device (CCD), a lightsensitive image sensor, at the instrument tip [76]. Images
were focused on the CCD chip by a small lens and were converted into digital signals that traveled to an image-processing
unit and were converted back to a visual image on a television
monitor. These modifications altered virtually none of the
other design elements of the endoscope and actually improved
instrument flexibility and image quality [3].
Digital endoscopy changed the way in which diagnostic
and therapeutic endoscopic procedures were performed. The
endoscopist could now view an enlarged image with both
eyes from a convenient distance and simultaneously record it
[77]. Furthermore, digital signals permitted image enhancement, noise filtering, and video transmission and recording.
Equally as important, the surgeon could now stand upright
and use both hands to operate in a coordinated fashion with
assistants and trainees viewing the same image simultaneously [78].
The coordinated efforts of surgeon and assistant increased
the complexity of endoscopic therapeutic interventions. In
the early 1990s, techniques for resection of large mucosal
lesions via endoscopic mucosal resection (EMR) permitted
removal of early GI tract malignancies without a formal surgical resection [79–81]. Even larger areas of neoplasia can
be removed via endoscopic submucosal dissection (ESD) in
which the endoscope is passed into the submucosal plane
beneath the mucosa. More recently, a modified version of
esophageal ESD has been utilized for the management of
achalasia. This method, per-oral endoscopic myotomy
(POEM), grew out of laboratory work performed in the
United States and was first performed in humans in Japan
[82–84]. It is now being performed clinically throughout the
world and by surgeons in a number of centers in the United
States [84–86].
Self-expanding metal stents (SEMS) were first introduced
in 1989 for the relief of malignant obstruction of the biliary
tree [87]. It was quickly recognized that the use of an expandable tubularized metal stent had potential benefit for other
malignant and recalcitrant strictures of the GI tract. In 1990,
Domschke, a gastroenterologist at the University of Erlangen


in Nuremberg, Germany, positioned a stainless steel SEMS
across a malignant esophageal stricture under endoscopic
guidance [88]. Soon, SEMS were being placed for palliation
of malignant gastric outlet and colon obstructions and as a
bridge to non-emergent surgery [89–91].
Over the last two decades, SEMS and, more recently, selfexpanding plastic stents (SEPS) have gained popularity and
shown tremendous therapeutic potential for stricture/obstructions of the esophagus, gastric outlet, and colon. Stents with
an external impermeable coating currently have an evolving
role in the management of enteric fistulae, perforations, and
anastomotic leaks.
The early twenty-first century saw the development of
numerous endoscopic therapies for gastro-esophageal reflux
disease (GERD) and its complications including endoscopic
gastroplasty, application of radiofrequency (RF) energy to
the lower esophageal sphincter, injection/implantation of a
bioprosthetic into the submucosa of the lower esophagus,
and ablation of Barrett’s esophagus with dysplasia [92–99].
Within the same time frame, endoscopists began to tackle
the growing world epidemic of morbid obesity, developing
endoscopic bariatric procedures with improved effectiveness compared with medications, but with a lower risk
profile than traditional surgery. Primary procedures for
weight loss have included the development of intra-gastric
space-occupying devices, barrier-type devices that permit
malabsorption, and endoscopic suturing devices to plicate
the stomach and restrict calorie intake [100–105]. Such
endoscopic suturing platforms have also been utilized as
revisional techniques for failed bariatric operations, permitting plication of dilated gastrojejunal anastomosis after
Roux-en-Y gastric bypass surgery or shrinkage of a dilated
gastric pouch [106, 107].
As endoscopic therapies grew in complexity, it was perhaps inevitable that the realm of minimally invasive laparoscopic surgery and therapeutic flexible endoscopy
would merge into a common area of technology and methodology called Natural Orifice Translumenal Endoscopic
Surgery (NOTES™) [108]. Introduced in the early 2000s
through exciting collaborations between surgeons and gastroenterologists, NOTES involves crossing the lumen of
the esophagus, stomach, colon, vagina, or bladder with an
endoscope to perform a surgical procedure in the intraabdominal space. The technique was first reported in 2000
by Anthony Kalloo, a gastroenterologist, and colleagues at
the Johns Hopkins Hospital in Baltimore, Maryland
(Fig. 1.11) [109–111]. An endoscopic full-thickness gastrotomy was made, pneumoperitoneum created, and endoscopic peritoneoscopy with liver biopsy performed. The
resultant gastrotomy was closed with endoscopic clips
[110]. Though in its infancy, the concept of translumenal
surgery has fired the imagination of the current generation
of surgical endoscopists.


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