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Should surgeons train in flexible interventional endoscopy ?

Anthony N. KALLOO, MD
Johns Hopkins Hospital
Baltimore, MD, United States

It is not the strongest of the species that survives, nor the most intelligent that survives.
It is the one that is the most adaptable to change. — Charles DARWIN

The last decade has witnessed a significant upsurge in the development of flexible interventional endoscopy (FIE). This is occurring not just because of the development of devices and tools to facilitate intervention but also because of the better understanding by flexible endoscopic researchers to adhere to fundamental principles of good surgical techniques in the development of new devices and procedures.

One example is the endoscopic approach to weight loss. Initially, there was great enthusiasm for endoscopic placement of gastric space-occupying devices (balloons). The weight loss with devices, although initially successful, suffered with recidivism. However, endoscopic sleeve gastroplasty (ESG), a flexible endoscopic procedure that emulates sleeve gastrectomy, a surgical procedure with decades of achievement, is now showing long-term success without the need for surgical incisions. The table below shows the evolution of several surgical procedures to widely accepted endoscopic procedures.

Evolution of Surgery to Endoscopy
Colonic polyps
Colonoscopy & Polypectomy
Bile duct stones
Bile Duct Exploration
ERCP, Sphincterotomy & Stone extraction
Pancreatic pseudocysts
Surgical Cystogastrostomy
Endoscopic Cystogastrostomy
Myotomy & Fundoplication
Bariatric surgery
Endoscopic bariatric procedures
Nissen Fundoplication
Transoral Incisionless Fundoplication
Motility disorders
Surgical myotomy, pacemaker implantation
Submucosal Endoscopic Interventions

So what is the surgeon to do? It is clear that digestive surgeons must fully embrace flexible endoscopy and flexible endoscopic interventions to avoid the risk of becoming extinct. This will allow them to be wholly capable to provide the best and least invasive care to patients. Centers like IRCAD that offer the opportunity for flexible endoscopic training should be embraced and flourish.

Should the FIE gastroenterologist perceive surgeons performing flexible endoscopy as a threat? The answer is no. Currently, there are an overwhelming array of interventional endoscopic procedures that no single gastroenterologists can be an expert in all procedures. Current interventional endoscopy fellowships are struggling to train their advanced fellows in all procedures that now include ERCP, diagnostic and therapeutic endoscopic ultrasonography (EUS), and bariatric endoscopy. Therapeutic EUS allows for the performance of bilioenteric and entero-enteric bypass. The new emerging field of submucosal endoscopy (third space endoscopy) that includes POEM, Z-POEM and the ability to use flexible endoscopy to intervene on every intestinal sphincter (whether to obliterate or enhance) will continue to grow. Submucosal endoscopy allows for the treatment of refractory strictures and for the safe removal of mucosal tumors. Yes, this is quite an overwhelming list and gastroenterologists should warmly embrace their surgical sisters, brothers, and partners to bring the best and least invasive care to patients.

Perhaps it is time to consider a new paradigm in medical training in our specialty of digestive disease. Instead of a bi-directional pathway following medical school to either surgical training or medical training, a single pathway of a digestive specialist capable of performing laparoscopy and flexible endoscopy may foster a pathway for a true minimally interventionalist. These are exciting times for those of us seeking minimally invasive solutions to better the care of our patients.