World News in Digestive Endoscopy
Issue 6, May 1997
OMED - OMGE: Two souls one body or two bodies one soul?
Since 1993, well before the World Congresses in Los Angeles, several
"diplomatic" encounters among officials of OMED and OMGE tried to define the
respective fields of activity and cooperation and the appropriate share of
responsibilities in the organization of the joint World Congresses. In fact those meetings
were seldom "diplomatic" because the respective positions were more and more
debated in what in diplomacy is called "frank" terms.
As the quadrennial mandate of the present OMED officials is nearing the end, we have to
say that no positive solutions have yet been reached. This certainly was not from
unwillingness on the part of OMED. In fact the requests from OMGE would practically absorb
OMED as an OMGE Committee, at the most. This is not in line with the basic philosophy
which lead to the creation of OMED in 1966, nor with the interests of those practicing
endoscopy, who want their specific activities considered on the front line of world
gastroenterology.
With this in view a document highlighting the future of OMED has been prepared. It will be
discussed at the extraordinary Assembly called at the DDW in Washington, but it is here
reported for a better knowledge by all the practicing endo-scopists around the world.
The Future of OMED
In order to fulfill its obligation to Gastrointestinal Endoscopy, OMED needs to a) be recognized as a partner in the World Congresses of Gastroenterology, and b) receive the financial support to carry out its goals in administration, education and research. It is the charge of OMED to ensure that is a proper balance of endoscopic topics and conferences at the World Congresses of Gastroenterology. To ensure that this happens, the following items should be instituted:
In order to accomplish its overall mission, the following need to be instituted:
Achalasia is a disease that, despite its relative rarity, remains very much in the
limelight and a matter for controversy. Since its original description, progress in
understanding the cause and mechanism of achalasia has been rather slow. The etiology of
primary achalasia is still unknown. However, it is now firmly established that achalasia
represents a neuromuscular disorder of the Lower Esophageal Sphincter (LES) that impairs
its normal relaxation. A significant finding in recent years has been that nitric oxide
synthase activity in LES tissue is markedly diminished (1). Nitric oxide is a key mediator
of sphincteric relaxation and deficient local production of this molecule may indeed be a
relevant pathogenetic factor. Nevertheless, we still do not know whether absence of nitric
oxide synthase represents a primary or a secondary defect.
For the diagnosis of achalasia we continue to rely primarily on manometric studies.
However, useful hints may be sometimes perceived at endoscopy, even in early cases without
evident dilatation of the esophagus, food retention or other gross signs of impaired
esophageal clearance. Recently data suggest that videoesophagography and scintigraphy can
match the diagnostic accuracy of manometry. Unfortunately these imaging techniques are
less accurate in distinguishing nonspecific motility disorders from normal, a drawback
that hampers their usefulness in clinical settings (2). Another important diagnostic issue
is the differentiation between gastroesophageal reflux disease and early achalasia. It has
been shown that patients with achalasia and heartburn have lower basal LES pressures that
those without heartburn. Moreover, the development of dysphagia is often heralded by
disappearance of longstanding heartburn (3).
The appropriate management of achalasia, although not free from debate, is being gradually
consensuated. Drugs may be tried in relatively mild, early cases. Nifedipine and other
calcium channel blockers are the preferred pharmacological agents. Unfortunately,
effectiveness is modest, side effects bothersome and drug therapy sometimes uncovers
underlying reflux disease. Thus, in most cases it is reasonable to proceed with dilation
as the first therapeutic step. Dilation has been made technically easier by balloon
devices that can be positioned across the gastroesophageal junction under direct
endoscopic guidance, thus obviating the need for fluoroscopy (4). Pneumatic dilation with
low compliance balloons is safe and long lasting (5). Reflux is a potential sequela (about
5-10%)but can be easily managed pharmacologically. Mechanical dilators perform similarly
to pneumatic dilation (6). Esopha-geal tears (transmural and non-transmural) are a
recogniz-
ed complication, but in many occasions may be treated conservatively (7). Depending on
different series, overall perforation risk has been rated at 3-6%.(8).
Botulinum toxin injection into the LES under endoscopic guidance is a tantalizing
alternative to dilation. It appears to perform better in patients older than 50 years and
in those with vigorous achalasia (9). The main disadvantage is the number of failures
(about one third) and the temporality of the response in favourable cases (1.3 years
average, but with a lower range limit of about 5 months).
Surgery is of proven effectiveness and has become more attractive to patients, and
referring physicians by the in-troduction of laparoscopic procedures (10, 11) . These
appear to provide satisfactory results, although follow-up is still relatively short (12).
Conventional Heller myotomy is the established surgical technique and if performed
skilfully it works well. Most important, the results of Heller myotomy are apparently
unaffected by whether dilation treatment has been attempted first (13), thus supporting
the customary ma-nagement approach of trying dilation prior to surgery. An unresolved
issue is whether an antireflux procedure should be added to myotomy. Some recent studies
(14) suggest that an antireflux procedure does not improve the clinical results. Follow-up
post surgery is important. Dysphagia recurs early postoperatively (usually in less than 3
years) whereas reflux problems may not become manifest until 10 years or longer have
elapsed (15). Quality of life post surgery is another relevant issue and a recent study
indicates that patients treated with cardiomyotomy are more restricted in sports
activities than those who received pneumatic dilatation (16).
Like many other uncommon and complex conditions, achalasia is best cared for by
experienced physicians who will sensibly take a step by step approach, always using the
best interest of the patient as their management principle.
Juan-R. Malagelada, MD
Chairman of UEGF 1997
Digestive System Research Unit - Hospital General
Vall d’Hebron - Barcelona, Spain
REFERENCES
At the United European Gastroenterology Week meeting in Paris during 1996 the European Society for Gastrointestinal Endoscopy staged three mini debates on the theme "Are we performing too many diagnostic endoscopies"?
The surveillance of Barrett’s oesophagus is a waste of time
It is well recognised that Barrett’s oesophagus is a precursor of adenocarcinoma of the lower oesophagus and many gas-troenterologists perform regular endoscopic screening with biopsy in order to detect dysplastic change so that active measures can be taken before the development of cancer. No controlled clinical trials have been undertaken to test whether this approach is clinically or economically desirable and depending upon the definition of Barrett’s oesophagus up to 15% of the dyspeptic population may have this condition. The practical implications for screening all patients with Barrett’s oesophagus is considerable. Professor Classen spoke for the motion and Professor Tytgat against.
Young dyspeptics (under 45) do not need OGD exploration
The main reasons for undertaking diagnostic endoscopy in dyspeptic patients are to detect oesophago-gastric cancer, identify peptic ulcer and assess the severity of reflux oeso-phagitis. Conversely a normal endoscopy is reassuring both to doctor and patient. Throughout the world more and more patients with dyspepsia seek medical advice and those attending gastroenterologists usually undergo endoscopy. In Western countries gastric cancer is rare in young patients and serological testing for Helicobacter pylori will identify 95% of patients with peptic ulcers. Young Helicobacter pylori negative patients who are not taking non-steroidal anti-inflammatory drugs and have no alarm symptoms can therefore be reassured that they have no serious disease, whilst those who are positive can receive treatment for Helicobacter which will effectively cure ulcer disease. Endoscopy is an insensitive and not particularly useful investigation in gastro-oesophageal reflux disease which in any event is usually managed symptomatically. Diagnostic endoscopy in young patients it was argued is unnecessary. Professor Axon spoke in favour of the motion, Dr. Papazian spoke against.
Pancreatic disease: Endoscopic diagnosis is obsolete
Until recently the most sensitive and specific investigation for pancreatic disease was
endoscopic retrograde pancreatography. It is however not without a certain risk. Acute
pancreatitis occurs in up to 10% of examinations (depending upon the skill of the operator
the definition taken for acute pancreatitis and chance) and most gastroenterologists would
agree that there is a need for a more sensitive investigation with fewer side effects. The
recent introduction of magnetic resonance scanning accompanied by computer assisted image
manipulation has enable the ductular system of the pancreato-biliary system to be imaged
non-invasively and with acceptable accuracy. It enables strictures and stones to be
identified in addition to demonstrating ductular irregularity. When combined with CT
scanning which provides an accurate assessment of the parenchyma (in particular the
presence of calcification), these two imaging modalities enable the pancreas to be
assessed without significant risk to the patient. Whilst a number of gastroenterologists
accept that ERCP remains an invaluable therapeutic tools its days as a diagnostic modality
maybe limited.
Dr. Kruse and Professor Cremer both spoke in favour of the motion.The mini debate was
attended by over 1,000 delegates, the auditorium was full and a significant number were
turned away for lack of space. Each of the debates was voted on and all three motions were
lost. The majority of gastroenterologists are conservative when it comes to phasing out
endoscopy and attitudes are unlikely to change until those who advocate a reduction in
endoscopy are able to make their point using hard data that will only be produced by
undertaking prospective clinical trials.
Anthony Axon, MD
ESGE Vice-President
Professor of Gastroenterology - Leeds, U.K.
Report on the 7th Asian-Pacific Congress of Digestive Endoscopy
The 7th Asian-Pacific Congress of Digestive Endoscopy was held in Yokohama, Japan, at
the Pacific Convention Plaza Yokohama from September 19 to 23, 1996 under the auspices of
the Asian-Pacific Society for Digestive Endoscopy with T. Sakita serving as President and
H. Niwa as Vice-President.
The 1st Asian-Pacific Congress of Digestive Endoscopy was held in Japan in 1973 and has
subsequently been held every 4 years in a different country in the Asian-Pacific region.
Again, the site of the Congress rotated to Japan in 1996. The Congress on this occasion
was jointly held with the 10th Asian-Pacific Congress of Gastroenterology, the 38th Annual
Meeting of the Japanese Society of Gastroenterology and the 52nd Congress of the Japan
Gastroenterological Endoscopy Society. The participants at the congresses totaled 8.712
including 7.692 from Japan and 1.020 from 51 other countries, as well as 114 accompanying
persons. Programs included 1 Keynote Lecture, 9 Special Lectures, 9 Quadrenial Reviews, 13
State-of-the-Art Lectures, 8 Joint Symposia, 1 Joint Panel Discussion, 8 Symposia, 1 Panel
Discussion, 6 Workshops, 4 Post-graduate Courses, and 807 oral presentations of Free
Paper. Most programs were organized jointly by the 4 Congresses and covered the most
up-to-date topics in endoscopic and gastroenterological medicine. Topics related
exclusively to Endoscopy were as follows; Special Lectures: The History and
Prospects of Digestive Endoscopic Medicine in Japan by H. Niwa. Joint Symposia:
GERD, gastric biopsy, gastritis, and Helicobacter pylori, peptic ulcer, diagnosis of early
gastric cancer. Symposia: Treatment of esophago-gastric varices, management of
upper gastrointestinal bleeding, endoscopic diagnosis and treatment of early colon cancer,
differential diagnosis of inflammatory bowel diseases, endoscopic ultrasonography. Workshop:
Barrett’s esophagus, parasitic gastrointestinal diseases, NSAID-induced
gastro-intestinal injury, inflammatory bowel diseases. Quadrennial Reviews: Laser
devices for endoscopy, education employing new visual technology, laparoscopy for chronic
liver disease, natural history of colorectal cancer. State-of-the-Art Lectures:
Endoscopic recanalization of malignant esophageal obstruc-tion, conscious sedation and
monitoring, chromo-endoscopy, a prospective study on endoscopic treatment of early gastric
cancer in Japan. Post-Graduate Courses: Endoscopic mucosal resection, biliary
drainage, endoscopic hemostasis, elegant colonoscopy, laparoscopic surgery.
In addition, the following programs were offered: 749 poster presentations, 58 video
presentations, 14 luncheon meetings, 6 satellite symposia.
As social events, 3 optional tours, 2 accompanying persons’ day tours and a
post-graduate tour were offered.
The Congresses featured a "Young Investigators’ Award", bestowed on 100
selected individuals, designed to encourage promising young investigators.
Although the Congresses were held in the Asian-Pacific district, there were many
participants from Interamerican and European countries. The 8th Asian-Pacific Congress of
Digestive Endoscopy is scheduled to be held in Hong Kong in the year 2000.
Hirohumi Niwa, MD
OMED Vice-President
President Asian-Pacific Society for Digestive Endoscopy
Tokyo, Japan
News from the XII Pan-American Congress of Digestive Endoscopy
The XII Pan-American Congress of Digestive Endoscopy will be held in Santo Domingo,
Dominican Republic, from November 17 to 21, 1997.
Organized by the Chapter of Endoscopy of the Dominican Society of Gastroenterology and
under the auspices of the Interamerican Society of Digestive Endoscopy (SIED), this
congress is part of GASTRO SANTO DOMINGO ’97, that is the XXV Pan-American
Congress of Digestive Diseases, the II Iberoamerican Congress of Gastroenterology and the
VI Dominican Congress of Gastroenterology.
In conjunction with these events there will be a Postgraduated Course of Digestive
Endoscopy on November 17, organized by Nestor Chopita, the President of the SIED and
Glaciomar Machado, President-Elect of OMED. Another Post-graduated Course of
Endosonography will also be held on November 17, organized by Jack Van Damme and his group
from the Brigham and Women Hospital, Harvard Medical School, Boston. A Workshop on
Therapeutic Endoscopy with life demonstrations will complete the endoscopic educational
activities. It will be transmitted to the Congress and Exhibition Centre and run by well
known endoscopists from the Americas, Europe and Japan. Among the Faculty: J.D. Waye, J.R.
Armengol-Miró, N. Sohendra, H. Grimm, L. Tio.
The submitted abstracts and posters will participate in a competition organized by he
SIED, were anyone will have an opportunity to win a prize.
An attractive social program, where the doctors will be able to participate in city, beach
and shop tours, will complete the event.
For additional information, please contact:
GASTRO SANTO DOMINGO ’97
Calle Santiago # 452, 2do piso
Gascue, Santo Domingo - Republica Dominicana
Phone: (809) 687 - 1515 Fax: (809) 687 - 7529
E- mail: g.bianco@codetei.net.do
Jose Ariel Ortega, MD
President XII Pan-American Congress of Digestive Endoscopy
Santo Domingo, Republica Dominicana
News from Vienna 1998:World Congress of Digestive Endoscopy and Omed Post-graduate Course
Vienna is looking forward to host the World Congresses of Gastroenterology from
September 6 to 11, 1998. The Steering Committee and the Local Host Committee have agreed
to prepare the scientific program for the Vienna World Congress in a format, that
accommodates contributions to the 11th World Congress of Gastroenterology, 9th World
Congress of Digestive Endoscopy and 6th World Congress of Coloproctology in a singular
integrated program. Thus it was and is the respon-sibility and privilege of the President
of the 9th World Congress of Digestive Endoscopy to solicit endoscopic topics of the
entire area of digestive endoscopy for appropriate presentation and discussion at the
World Congress. The Scientific Program Committee so far has received a good number of
suggestions of topics and distinguished speakers and I am grateful particularly to Prof.
Massimo Crespi, the Secretary General of OMED, who has coordinated many activities in the
preparation of the scientific program. In my capacity as the President of the 9th World
Congress of Digestive Endoscopy I had the pleasure to extend invitations for the Moutier
Honorary Lecture, the Schindler Honorary Lecture and the Tasaka Lecture.
In addition to a full representation of endoscopic topics in the scientific program, the
World Congresses of Gastroenterology will again be an excellent opportunity to implement
the Post-graduate Endoscopy Course under the auspices of OMED. The course directors Alfred
Gangl (Vienna), and Meinhard Classen (Munich), supported by Rainer Schofl (Vienna), as
Secretary and a highly distinguished international faculty and scientific board have
agreed to a program on advanced endoscopy, covering the topics variceal bleeding,
non-variceal bleeding, endosonography, bile duct stones and stenoses, chronic pancreatitis
and polyps and cancer of the lower GI-tract. State of the art presentations and video case
presentations with possibilities for discussion with panelists and auditorium including
the use of an interactive voting system shall be the basic elements for an educative,
interesting and lively course, in which some of the leaders of our field will share their
knowledge and experience in the most recent advances in digestive endoscopy as they
present and discuss challenging clinical situations.
The success of the World Congress of Digestive Endoscopy depends very much also on the
intellectual input of the membership of OMED and on your active participation. Therefore
get ready and make room on your calendar now for what we hope to be a remarkable World
Congress of Gastroenterology in September 1998 in Vienna.
Alfred Gangl, MD
Professor of Gastroenterology and Hepatology
Chairman of the Department of Medicine IV
University of Vienna, Austria
Urgent Endoscopic Sphincterotomy for Acute Biliary Pancreatitis
According to the Opie’s theory Acute Biliary Pancreatitis (ABP) in triggered by
biliary stones obstructing of migrating through the papilla of Vater (1). The progression
from mild to severe pancreatitis may be the consequence of repeated episodes of
obstruction by multiple biliary stones or permanent obstruction by the stone blocked in
the papilla (2). It seems logical, that the earlier relief of obstruction should
ameliorate the outcome of ABP. However, the results of early surgical treatment were
contradictory, and in some reports mortality remained unacceptably high (3). ES for
biliary pancreatitis was first reported by Classen et al. in 1978 (4), and then followed
by the series of non-randomized trials, showing the benefit of early endoscopic treatment.
The first prospective randomized trial, comparing early ES (within 72 hours from
admission) vs. conventional management was done in England (Neoptolemos, Carr-Locke,
London et al.) in 1988 (5). They showed two-fold decrease in morbidity (24% to 12%) and
six-fold decrease of mortality (12% to 2%) in favor of endoscopic treatment. Statistically
significant difference was, however, observed only for complications, and only in the
group with predicted severe ABP (61% vs. 24%; p <0.01).
The next randomized trial came from Hong Hong (Fan, Lai, Mok et al.) in 1993 (6), but few
methodological drawbacks decreased its value. It was found that the incidence of biliary
sepsis was significantly lower with ERCP/ES. However, ES was done within 24 hours of
admission only in 40% of patients randomized for such treatment. No statistical
significance was achieved, although trends (complications 30% vs. 18%; mortality 8% vs.
2%) strongly favored endoscopy.
The next randomized trial was done in Germany (Fölsch, Nitsche, Lüdtke et al.) in 1995
(7), with completely different results. They concluded that in patients in ABP and no
obstructive jaundice ERCP and ES were not beneficial. Unfortunately, in invasive group
(ERCP/ES) only 48% (with CBD stones) of patients received ES. The second weak point was
the fact, that in this multicenter study some centers enrolled less than 10 patients, what
may rise the question of experience. The ES in patients with ABP is sometimes much more
difficult, especially in patients with no jaundice and narrow CBD.
In 1995 and 1996 two studies from Poland (Nowak, Nowakowska-Dulawa, Marek et al.) were
presented during DDWs in San Diego and San Francisco (8,9).
The first (8) comprised 280 patients with ABP. All patients underwent urgent (< 24
hours of admission) duodenoscopy. 75 patients with stones impacted in the papilla were
treated by immediate ES. Remaining 205 patients were randomized to receive immediate ES
(103 patients) or conventional management (102 patients). ES was able to decrease
complications rate from 38% to 17% (p <0.001) and mortality rate from 13% to 2% (p
<0.001). Both differences were significant for predicted severe as well as for
predicted mild cases.
In the second study (9) they were able to prove, that the timing of the intervention is
one of the most important factors influencing the outcome in patients treated
endoscopically. In their group of 263 patients treated by urgent ES there were no deaths
and 6% of complications for patients treated in the first day of the disease, 2% mortality
and 17% of complications for patients treated between 24 and 72 hours from the onset of
the disease, and 13% mortality with 30% of complications when the delay from the beginning
of the disease exceeded 3 days. Both trends were highly significant (p <0.001).
It could be concluded on the basis of above mentioned studies, that the urgent ES should
be the treatment of choice for all cases of ABP, independently of predicted severity. To
achieve the best results of treatment, ES should be done as quickly as possible, ideally
in the first day of the disease.
Prof. Andrzej Nowak, MD
ESGE Vice-President
Department of Gastroenterology, Silesian Medical Academy Katowice, Poland
REFERENCES
A) Type C Hepatitis and endoscopy
As stated in the ESGE guidelines for cleaning and disinfection of endoscopes and
accessories, all endoscopy procedures are connected with a risk of spread of various
micro-organisms from one patient to another or from infected patient to staff members.
Following recent publications concerning potential risk of transmission of type C
hepatitis by endoscopy, the ESGE has reconsidered the previously issued guidelines
focussing on this item and is satisfied to conclude, that adherence to these guidelines
will effectively prevent transmission of hepatitis C. The adherence to the ESGE guidelines
means to perform cleaning and disinfection of endoscopes and endoscopic accessories
strictly sticking to the instructions pointed below:
B) Creutzfeld-Jacob disease and endoscopy
As infectious agent little is known on prions, thus it is difficult to detect and
to eradicate from endoscopes. The risk of transmission of prions by endoscopy however is
probably low, because the prions may not be present in the gastrointestinal tract or even
in the blood.
Attempts to eradicate the prions by chemical or thermal methods would destroy the
endoscopes. If an endoscope has been used in Creutzfeld-Jacob patient, it should either be
destroyed or reserved for later Creutzfeld-Jacob patients. As Creutzfeld-Jacob disease is
rapidly deteriorating and – in the moment – incurable illness, endoscopic
procedures in these patients might be considered as a prolongation of the inevitable death
rather than an improvement of quality of life. Thus usual indications for endoscopic
procedures in this population of patients are waived.
The indications for endoscopic procedures in Creutzfeld-Jacob patients (who are not
moribund) should include:
– sudden total dysphagia (removal of foreign body);
– life-threatening upper or lower gastrointestinal bleeding (hemostasis);
– acute cholangitis and acute biliary pancreatitis with sepsis (biliary and
pancreatic ducts decompression).
Patients with strong suspition of Creutzfeld-Jacob disease must be managed as if the
diagnosis was already done.
The very low prevalence of Creutzfeld-Jacob disease could justify organisation on a
national basis of one or two centers for treatment of these patients. Such centers might
be provided with special endoscopes and endoscopy accesories, disinfectors, separate
examination rooms.
Introduction of endoscopes with the possibility of patient-to-patient change of single-use
(disposable) protective sheath that contains all the working channels could be a cheaper
solution. This kind of endoscope ensures a 100% sterile instrument for each patients
procedure and eliminates staff contact with and exposure to hazardous germicides. Such
fiberoptic endoscopes are just under the clinical evaluation.
Any endoscopic accessory used in Creutzfeld-Jacob patient should undergo a high level
disinfection before sending for destruction (by heat). After every endoscopic procedure
endoscope must undergo cleaning and disinfection process repeated 3 times before storage.
If sent for repair, a special warning must be given to the repair performers.
A.Kruse, MD - J.F. Rey, MD
ESGE Disinfection Committee
Following the resignation of Dr. Stiel, it was my great honor to be nominated to
succeed him as Chair of the Research Committee, which became effective in May 1996. I now
have the pleasure of updating you on current and planned activities of the Research
Committee. Several activities are currently in hand.
A major priority for the Research Committee is the development of an international
database on endoscopic priorities. If the Research Committee is to serve as a voice for
endoscopic research in the future it is clear that we need data to indicate the important
priorities for the development of endoscopy in various parts of the world. Each member of
the Research Committee has, therefore, been charged with compiling a list of the most
important diagnostic and therapeutic uses of endoscopy in their part of the world. This
data will be collated and should be of considerable assistance in the development of
research and educational strategies appropriate to different parts of the world. It is my
impression that, contrary to popular belief, endoscopy may, in fact, be a very important
and almost basic medical tool in many parts of the world, including the developing world,
yet priorities may be quite different.
In the past, the Research Committee, OMED and the World Congress have addressed the issue
of endoscopic disinfection. I am pleased to announce that the Organizing Committee of the
Vienna World Congress have asked me to chair a working party on minimal standards for
endoscopic disinfection. While this will be performed within the auspices of a separate
working party, the results of this group should be of considerable value to OMED and its
Research Committee. Along similar lines, the OMED Research Committee is also working to
develop a consensus document on minimal standards for the performance of endoscopy. Our
goal here is to establish, through data generated by members of the Research Committee,
what are, indeed, the basic requirements for the performance of diagnostic and/or
therapeutic endoscopy in various parts of the world. This information should, again, help
to provide an appreciation of variations in endoscopic priorities throughout the world,
help delineate areas of mutual interest and also assist in developing specific protocols
for different parts of the world. Building on this, we also hope to address the
standardization of accessory equipment.
A proposal for a multicenter study of Barrett’s esophagus, intestinal metaplasia and
adenocarcinoma is under review and proposal in the area of endoscopic hemostasis and
laparoscopy will be considered.
The Research Committee will meet in Washington DC, at the time of Digestive Diseases Week
– we anticipate lively discussion, and I look forward to updating you of the
continuing activities of the OMED Research Committee.
Eamonn M.M. Quigley, MD, FRCP
Chairman OMED Research Committee
University of Nebraska, U.S.A.
Actions by the Omed Education Committee
OMED is embarking upon a two-part approach to teaching endoscopy in under developed
countries. The overall plan is to present videotape demonstrations of endoscopic
procedures to a national meeting at which all people who are interested in
gastrointestinal endoscopy and gastroenterology will be invited. The group of people who
express an interest in forming endoscopic centers will subsequently (within one year) be
invited to attend a practical workshop on endoscopy in that country. Cases will be
provided and experts will demonstrate various techniques of basic endoscopic procedures.
Lectures and written material will be developed for those basic workshops. The first area
contacted for this approach is Africa. Communication has been established with professor
Simjee, president of the newly-formed African Federation of Gastroenterology. He has
expressed an interest in this program and is currently contacting physicians who may be
interested in this approach.
A cadre of teachers in endoscopy is being developed for purposes of teaching endoscopy in
underdeveloped countries. If anyone would like to be nominated as a member of the OMED
teaching faculty, please contact me with a brief resume detailing your endoscopic
experience, the hospitals in which you were trained, a description of the level of
expertise, and the types of endoscopy in which you are interested in teaching.
The education committee is attempting to act as a repository for the collection of
constitution and by-laws of endoscopic societies throughout the world. This will allow us
to know which organizations have established by-laws, and the languages in which they are
written. Upon request from any group which is considering formation of an endoscopic
society, or which would like further information on patterns which have been developed by
other organizations, the names of the endoscopic societies and a specific contact person
will be sent so that communications can be established between various endoscopic
societies for the exchange of this information. At the present time, the education
committee has received twelve responses. The committee has also requested information
concerning teaching videotapes and guidelines which have been established for endoscopy.
The American Society for Gastrointestinal Endoscopy, seems to have the best-developed set
of guidelines. The British Society of Gastroenterology also has several endoscopic
guidelines available.
In order to facilitate communication between endoscopic societies and endoscopists
worldwide concerning items of interest, OMED is currently on the internet at: www.uni. net/omed. The E-mail address is OMED@uni.net.
Videotapes of the Post-graduate Courses of the last two World Congresses of
Gastroenterology, held in Sydney and Los Angeles, are currently available at no cost for
national organizations who request them from the OMED General Secretariat. The stipulation
is that they will be shown at a National Congress of Gastroenterology within a year after
their having been received by the national Society.
They will be also available to individual physicians by request. They are in two formats,
PAL and NTSC. The price for the complete package of 13 videotapes is $ 100 US. This is to
defray the cost of videotapes and mailing. The requests should be addressed to Prof.
Massimo Crespi, National Cancer Institute "Regina Elena", Viale Regina Elena 291
- 00161 Roma, Italy -
Fax +39.6.4457086 E-mail: as stated above.
Jerome D. Waye, MD
Chairman OMED Education Committee
New York, U.S.A.
Teaching Endoscopy by Interactive Videotapes
Teaching endoscopy has evolved from artist’s reproduction of endoscopic findings,
through the direct capture of high quality still and video images. The limitations of
teaching were primarily related to the need for a one on one or very small group
experience. The electronic endoscope brought large screen T-V to the teaching environment
and a large number of remote transmissions from international centers soon evolved via
satellite or telephone lines. The two most important limiting factors to the remote, live
transmission technology are the down time during complicated cases, and the costs involved
for a one time use.
A radically different approach has been developed by Advance Medical Ventures, a Hollywood
based company that utilizes professional motion picture production and editing crews as
well as state-of-the-art presentations designed to capture the "live
atmosphere".
The format is the presentation of a wide range of pretaped video sequences of procedures
actually performed by experts in their individual endoscopy units. In addition to large
screen projection, a high quality sound reproduction system and multiple high resolution
video monitors are spaced through out the presentation center allowing close-up
demonstrations of the technical aspects of complicated therapeutic endoscopic techniques
that were performed under real practice situations.
The direct video reproductions are enhanced by split screen technology allowing the
audience to focus on many aspects of the procedures with simultaneous visualization of the
high resolution endoscopic images. The use of stop-start and rapid rewind methods have
been combined with both recorded and live voice-over explanations by the on-site faculty
presenters who were filmed in their own units. The audience is further involved in the
sessions through the use of interactive "touch-pad" questions and the presence
of an expert endoscopic "facilitator" who anticipates questions and the need to
review special technical aspects of the presentations. The facilitator is as well scripted
with time code associated material so that by watching a special monitor he can amplify
certain teaching points agreed with by the faculty in pre-presentation rehearsal sessions.
A special teaching technique is further provided by "telestrator" technology
that allows the expert presenter to draw over or provide diagramming to emphasize
particular concepts.
This teaching concept was developed over five years ago and has been utilized at the World
Congresses of Gastroenterology Post-graduate Endoscopy course in Los Angeles in 1994 and
at the American Society for Gastrointestinal Endoscopy’s annual Post -graduate
teaching course in San Francisco in 1996. Parts of the program have been reproduced
internationally at the UEGW, and at regional society meetings. New endoscopic material is
provided every two years so that the latest in technology is provided as well as the
opportunity for individuals who have attended previous presentations to return for new
material. The attendance evaluations have universally indicated that the program is
extremely well received.
The high quality video material has been reproduced on video cassettes for international
distribution, and lends itself to the new electronic formats such as DVD and CD-ROM. This
enables continued study outside of the presentation environment.
The teaching format has been used by small groups such as a hospital that invites 50
physicians to a meeting, or by large groups with attendance exceeding 2000. Further
information concerning presentations and materials are available on the AMV home page: http://www.amv.com.
Melvin Schapiro, M.D.
Center for the Health Sciences
University of California, Los Angeles, U.S.A.
Is Sphincter of Oddi Manometry Worthwhile?
Manometric studies of the Sphincter of Oddi (SO) were developed in the late 1970’s
to early 1980’s initially with the aim of conducting physiological studies on the SO
and biliary tract. The developments were made possible by the production of minimally
compliant water-perfused systems which were designed to work with miniaturised multi-lumen
catheters that were inserted into the lumen of the SO to study its motility. As a result
of those studies, in both animal models and subsequently in man, our understanding of the
physiology of the SO increased substantially. It was recognised that the SO modulates flow
of bile and pancreatic juice into the duodenum. In addition, it acts as a barrier to the
reflux of duodenal (DUO) contents into the bile duct and Pancreatic Duct (PD). Studies on
different populations of patients then identified abnormalities in manometry. Soon
thereafter, these manometric disorders were correlated with clinical syndromes.
The first clinical syndrome that was identified was that of dysfunction of the bile duct
SO. This condition usually presents in patients some years after they have had their
gallbladders removed mainly for gallstones. Approximately 5 years after cholecystectomy a
percentage of patients present with recurrent symptoms that are very similar to those that
were experienced prior to their cholecystectomy. Inevitably, an examination of the biliary
tract is made and no structural abnormalities or stones are found to account for the
symptomatology. SO manometry has allowed the identification of motility disorders of the
biliary sphincter which have been shown to correlate with the symptomatology.
A separate group of patients are those who present with Idiopathic Recurrent Pancreatitis
(IRP). Similar studies conducted on the pancreatic component of the SO have identified
motility disorders of the SO which have been shown to correlate with a group of patients
presenting with IRP.
Prior to these studies, a number of names were used to describe clinical syndromes that
were attributed to the SO. As a consequence of describing the manometric disorders which
corresponded to the above defined clinical syndromes, we introduced the term "SO
Dysfunction" to encompass all of the motility disorders of the Sphincter of Oddi.
SO dysfunction encompasses all of the motility disorders of either the biliary component
or pancreatic component of the SO. It does not relate to aetiology but only directly to
the motility disorders. These motility disorders have been determined by careful
manometric studies in eligible patients.
The clinical usefulness of SO manometry has been demon-strated by a series of clinical
studies which evaluated its role in the management of these conditions. In the first major
study to have looked at this problem prospectively, patients were randomised to either
sphincterotomy or a sham procedure and their symptoms evaluated over the course of five
years. All of these patients had undergone biliary manometry and on analysis it was shown
that patients with SO stenosis as characterised by an elevated SO basal pressure, were
cured following endoscopic sphincterotomy. In a more recent study, patients with
manometric abnormalities were prospectively randomised to either sphincterotomy or a sham
procedure. In this trial which used manometry as the basis for randomisation, it was also
found that patients with an elevated SO basal pressure are cured after endoscopic
sphincterotomy.
A similar finding has been noted in patients with IRP. Patients with manometrically
defined SO stenosis and IRP were cured after total division of both the biliary sphincter
but also the pancreatic duct sphincter.
Consequently, over the last decade and a half, SO manometry has been used firstly to
define the normal physiology of the SO then to identify manometric disorders and associate
these disorders with clinical syndromes. The adaptation of these findings to prospectively
randomised trials has indicated that when an elevated SO basal pressure is noted, then
division of the sphincter will result in long term resolution of the clinical problems.
How good is SO manometry? Currently the common means of performing SO manometry is via an
endoscopic approach. This allows the introduction of the manometry catheter into either
the bile duct or the pancreatic duct to then record the pressures from across the SO. By
necessity, this approach only samples briefly the activity of the SO. We know from patient
sympto-matology that the symptoms are mostly intermittent. Consequently, at best, SO
manometry can only detect the most severe of changes. Those motility abnormalities which
may be either intermittent or in response to various stimuli, cannot be readily detected
by this technique. Despite these limitation, studies that have been conducted in our
laboratory have shown that human SO manometry is highly reproducible.
A concern regarding manometry is the fact that this is an invasive procedure which may be
associated with compli-cations. The most common complication is pancreatitis with an
incidence of approximately 6%. This is quite acceptable as in most patients it is only
minor in nature and only marginally higher that the incidence reported for routine ERCP
and/or endoscopic sphincterotomy. However in some centres, the incidence of pancreatitis
has been alarmingly high and has been associated with complications. We have always
advocated the performance of SO manometry as a separate procedure to ERCP. This has the
disadvantage of two procedures on a patient; i.e. ERCP to radiographically visualise the
biliary and pancreatic systems and then manometry on a separate occasion. We believe that
our low incidence of pancreatitis with SO manometry is due to the fact that the manometry
is not added to the diagnostic ERCP. Others have advocated the use of modified catheters
so that the perfusion into the pancreatic duct is limited by aspiration. This technique
has also had the result of reducing the incidence of pancreatitis but has the disadvantage
of reducing the number of ports that can be used for the recording of pressure changes.
A number of other investigations have been used to evaluate patients who present with
recurrent biliary pain or IRP. The aim of alternate investigations is to develop a
non-invasive test that will assist in identifying those patients who will respond to
division of the SO.
Symptoms, signs and routine plasma investigations have not been shown to be predictive of
SO dysfunction nor outcome following endoscopic sphincterotomy. Rarely, one may be
presented with a patient with abnormal liver enzymes, a dilated duct and recurrent biliary
type pain. Invariably, SO manometry shows a stenosis and in these patients endoscopic
sphin-cterotomy is successful in relieving their symptoms. However, such patients are not
common and it is only in this instance where the symptoms and ERCP findings alone may make
manometry unnecessary.
The morphine-provocation test has in the past had its advocates. Studies performed by us
and others have shown that there is a good correlation between abnormal
morphine-provocation tests and manometric abnormalities in the SO. However, the
correlation is not tight and the morphine-provocation test consequently fails when used to
predict outcome of treatment.
A recently resurrected investigation has been the evaluation of flow through the bile duct
of radionuclide. These flow studies appear to correlate well with abnormalities in
manometry. However, it is yet to be shown whether there is good correlation with outcome
following treatment.
Studies using ultrasonography have been developed both for the bile duct and pancreatic
duct sphincter and are aimed at evaluating duct size in response to a provocative
stimulus. Whilst this investigation has been shown to correlate well with severe
manometrically detected stenosis, there is again no support for it when compared to
outcome following treatment.
Despite limitations, SO manometry remains the "gold standard" investigation for
the evaluation of patients suspected of SO dysfunction. These patients present with either
recurrent biliary type pain following cholecystectomy or IRP. The investigation does have
a low incidence of complications however if carefully performed under recommended
guidelines, the morbidity is not greater than that for other endoscopic biliary/pancreatic
or pancreatic procedures. Currently it is the only objective parameter which identifies
patients who will respond to division of the SO. However, it should be remembered that
manometry as currently practiced only samples SO activity for a short period of time.
Hence, there is the need to develop techniques which are able to study SO motility for a
prolonged period of time and during times of provocative stimuli.
James Toouli, MD
Professor of Surgery Head-Gastrointestinal Surgical Unit
Department of Surgery - Flinder Medical Centre
Adelaide, Australia
REFERENCES
Diagnostic Ultrasound and Video Assisted Surgery
Diagnostic ultrasound with the introduction of the grey-scale and the real-time
scanning became a valuable imaging modality more than 20 years ago.
To a certain extent, because of economics, very trivial access problems and in force of
the possible utilization in virtually every field of medicine and surgery, ultrasonography
has brought about a revolution in the work of diagnosticians, having greater magnitude
than the other two highly esteemed imaging modalities, namely CT and MR.
Probably, surgical problems have benefited the most by the introduction of diagnostic
ultrasound and, lately, by interventional ultrasonography.
Nevertheless, surgeons around the world, with a partial exeption of Italy and France, have
always profited by somebody else’s competence, mainly radiologists, to perform U/S
examinations on their patients, even in the operating room.
Lately, things are changing most probably in consequence of another technological
revolution in the field of surgery: the Video Assisted Minimal Access Surgery. The main
characteristic of this new way to perform surgery, unlike the traditional open surgery, as
everybody knows, is that the surgeon works looking at two-dimensional images on a monitor
and handles the surgical tools outside the body instead of looking and manipulating the
viscera directly in the operating field.
The consequence is that surgeon’s hands cannot palpate the viscera, which could have
the utmost importance during an operation.
In other words, diagnostic ultrasound during Video Assisted Surgery has the same potential
as the traditional intraoperative ultrasound and in addition may represent a valuable
surrogate of the palpating hand.
With the wide and rapid diffusion of this technology, surgeons are realising that the
optimization of this U/S examination during LAP or VAT surgery is obtained when the
surgeons themselves handle the probe and look at the images. This is why the post-graduate
courses on "Ultrasound for the surgeon" that were held during the last two
Meetings of SAGES and ACS were so successful.
In the very near future this competence is going to be mandatory for surgeons involved in
what we might call "Progressive Surgery".
Improvements are expected in the technology of U/S, from the threedimensional real-time
mapping of organs to the robotic handling of the laparoscopic U/S probe.
I am directly involved in this project. It is very likely that a live demonstration with a
prototype of this robotic arm will be performed during the 6th World Congress of
Endoscopic Surgery to be held in Rome, the first week of June 1998.
Licino Angelini, MD, FACS
Professor of General Surgery University "La Sapienza" Secretary General SIC
Governor at Large for Italy of ACS
Rome, Italy
Therapeutic Endoscopy in Asia*
In the past few decades endoscopy has revolutionised the practice of gastroenterology.
In the 1970’s flexible endoscopy was established as an essential diagnostic tool; the
1980’s saw explosive development in therapeutic endoscopy; by 1990 the technology has
matured: diseases that required open surgery in the past can be safely and effectively
managed by endoscopy. The advantages are obvious to both the patient and the doctor alike:
minimal post-operative discomfort, reduced hospital stay, shorter convalescence and a more
rapid recovery. Expertise in therapeutic endoscopy, for example ERCP and sphincterotomy,
is still confined to a few centres of excellence in many parts Asia. As the next
millennium approaches, the challenge is how to make the new technology more widely
available.
The problems of developing therapeutic endoscopy in Asia are particularly daunting.
Endoscopes and accessories are expensive and resources are limited in many developing
countries. As the technology is new, the traditional apprentice system of observation,
tutelage and practice under supervision by a mentor is inadequate. The expertise simply
does not exist amongst the senior staff in areas where therapeutic endoscopy is not
available. Therapeutic endoscopy requires complex cognitive and manual skills that can
only be acquired after a long period of training. Experimenting with a side viewing
endoscope or colonoscope without proper training is unlikely to be rewarding. Not only
would the patients be put at risk, the team would be discouraged and disillusioned by
failures and complications, and the new techniques would be discredited.
A period of observation at a centre of excellence is the traditional way for a young
surgeon to polish his skills. Therapeutic endoscopy, particularly ERCP, requires complex
hand-eye co-ordination that cannot be learned by observation alone. For obvious reasons of
patient safety and medico-legal considerations, few if any centres are willing to offer
short term visitors hands-on experience in potentially hazardous procedures. Practical
training is therefore only available to the very lucky few. A centre that intends to
provide training for endoscopists from overseas must have a large referral base to
generate enough clinical material, resources to cover the extra wear and tear on
endoscopes and accessories occasioned by inexperienced trainees and dedicated teachers to
teach and supervise. Licensing of foreign medical practitioners, cultural and language
differences, medico-legal issues and conflict of interest between local and overseas
trainees are problems that must be addressed. Despite large investments of time and
resources by both the trainee and training centre, only a small number of endoscopists can
be trained at any one time. Such intensive one-on-one training will only make an impact if
the trainee, in turn, is willing and able to pass on his skills when they return to their
country of origin.
Modern endoscopy uses video images. Such images can be easily transmitted to a conference
hall, or indeed across continents using satellites. Workshops in therapeutic endoscopy,
where experts demonstrates new techniques to a big audience, have become increasingly
popular in many countries throughout Asia. The therapeutic endoscopy workshop held in Hong
Kong every December attracts more than 300 participants annually. These workshops provide
an excellent forum for introduction of new technology, and for experienced endoscopists to
pick up fine points of technique from the experts. Such large scale workshops does not
truly reflect everyday practice and obviously cannot replace hands-on training.
One novel method of teaching endoscopy is the "master-class" borrowed from the
training of musicians: a group of advanced trainees perform, one after the other, in the
presence of the maestro. The maestro then gives a critique of each student’s
technique. This format creates an intense learning atmosphere and the trainees learn from
each other as well as from the maestro. The logistics of organizing such an event is
daunting, but a well-organized "master-class" can generate enormous enthusiasm
and is an efficient way of using the time of visiting experts. A series of such
"master-classes", conducted by Peter Cotton, Joseph Leung and Nib Soehendra in
China, were very well received.
Success of an endoscopic procedure depends on fine control of the endoscope, good hand-eye
co-ordination, intimate knowledge of the accessories as well as co-operation between the
endoscopist and the assistant. These manipulative skills can be acquired in a laboratory
setting. Animal models of ERCP and sphincterotomy are available, but they are expensive
and differ anatomically from humans. Computer simulators of colonoscopy and ERCP are also
available. At present their high cost preclude their widespread use in most Asian
countries. We have found that a very simple model using a bent piece of water hose can
expedite training in ERCP (1). The novice can learn about the peculiarities of the
side-viewing endoscope, the transmission of fine movements from the controls to the scope
tip and manipulation of accessories in a leisurely way without putting patients at risk.
Once the control of the endoscope becomes instinctive, the learning process in patients is
much more efficient.
Therapeutic endoscopy is has a bright future in Asia. There is a wealth of clinical
material and most countries in Asia are, as yet, relatively unrestricted by bureaucratic
and medico-legal problems. A number of centres with strong committents to teaching exists
in the region and the number of skilled endoscopists have already exceeded "critical
mass". With the rapid pace of economical development in the region, the next decade
will witness an exponential growth in therapeutic endoscopy in Asia.
SC Sydney Chung, MD, FRCS(Ed) FRCP(Ed)
Professor of Surgery - The Chinese University
Hong Kong
REFERENCE
Update on Helicobacter pylori Infection
Helicobacter pylori infection is a transmissible bacterial infection of the gastric mucosal surface that causes progressive damage with eventual destruction of the stomach. In the United States, the presence of H. pylori infection carries with it a lifetime risk of peptic ulcer of at least 16% and a 1% to 3% risk of gastric cancer. In many countries the risk of cancer is higher. Infected individuals are a risk to the community as the infection can be transmitted to others. H. pylori is the only treatable infectious disease with such a high rate of morbidity and mortality that is not the subject of an all out program to eradicate it from the population. The question is not whom to treat, but whom to test. If the tools were available, we would recommend screening the population for the presence of H. pylori infection with the goal of eliminating H. pylori from the face of the earth as was done with smallpox. Successful therapy requires combination therapy for one to two weeks. Therapies I recommend include BMT quadruple therapy (bismuth, metronidazole 500 mg t.i.d., tetracycline-HCl 500 mg q.i.d., plus a PPI) for 14 days, MCppi triple therapy (metronidazole 500 mg b.i.d., clarithromycin 250 or 500 mg b.i.d., and a PPI) for 14 days, or RBC triple therapy (RBC 400 mg b.i.d., clarithromycin 500 mg b.i.d., and metronidazole 500 mg b.i.d.). I recommend 14 days instead of 7 days as it gives better results in the face of drug resistant H. pylori which are increasingly a problem. I think that goals such as "therapy must be no more than twice a day therapy for no more than 7 days" are foolish as the actual goal is to be able to cure 100% of infections; whatever works best, is best. I believe that a urea breath test should be done to confirm that therapy was successful in every ulcer patient because the actual costs and risks associated with treatment failure outweigh the minor potential savings associated with waiting until the patient returns with symptoms or ulcer complications. Current studies of cost effectiveness actually do not assess costs such as costs associated with transmission, ulcer complications, lost time from work, development of cancer, etc., but rather evaluate easily available charges. My guiding principle is: "Do not test, if you are not willing to treat". Who then, should we be willing to treat? Based on the available evidence, we should treat all patients with active or previous peptic ulcer disease. The second group of patients is those with dyspepsia. I believe that patients with dyspepsia and no alarm symptoms should be investigated for "symptomatic H. pylori infection" by serology or UBT and those with infection should be treated. I also test and treat those at increased risk of gastric cancer or peptic ulcer. Such individuals can be identified with some degree of certainty on the basis of the presence of disease in a first-degree relative. The bottom line is that no one deserves, needs, wants, or benefits from having an H. pylori infection. Positive diagnosis of infection must be followed by treatment. I predict that endoscopy will play a decreasingly important role in the diagnosis and management of H. pylori infection.
David Y. Graham, MD
Veterans Affairs Medical Center
Houston, Texas, U.S.A.
A bird of ill omen could say "What’s new in GI endoscopy is that there is
nothing new and GI endoscopy is entering a time of uncertainty". This provocative
affirmation is founded on the fact that since the development of Endoscopic
Ultrasonography (EUS) in the early eighties, no new promising field has emerged in the
domain of GI endoscopy. The newly-born small bowel endoscopy has limited applications and
EUS itself is still criticized, as its impact on the patient management is limited.
Furthermore, we now assist at the come back of digestive radiology. Endoscopy and
retrograde cholangiography supplanted a time baryum radiography and percutaneous
cholangiography; the radiologists are now exploring digestive tract and biliopancreatic
ducts with new or improved tools: ultrasonography is becoming efficient for the diagnosis
of acute intestinal pathology and for the follow-up inflammatory bowel diseases; magnetic
resonance imaging using a body or an endoluminal surface coil could compare favorably with
EUS in the staging of cancer; magnetic resonance cholangio-pancreatography has set off at
full speed. Finally, virtual GI endoscopy by fusing reconstructed three-dimensional CT
scan is announced. The main reason for this evolution is that computer technology which
contributes to improve resolution of images and permits their reconstruction is more
adapted to radiologic images then to endoscopic images. As another main advantage, the
radiologic methods do not require sedation.
In fact, we are far to assist to the funeral of digestive endoscopy. Major changes are
going on in this domain.
First, endoscopy has entered an area of consolidation and standardisation: guidelines have
been edicted on 1) the endoscopy suite, 2) the reprocessing and maintenance of material,
3) the preparation, sedation and monitoring of patients, 4) the role of the
gastrointestinal assistant, 5) the reports, _etc. Collaborative controlled trials have
multiplied to evaluate the method. Journals, societies and training programs are abundant
and active. The main evolution in this field concerns the reprocessing of the material and
major question have still to be solved: 1) disposable endoscopes versus washing machines?
2) disposable versus non disposable accessories?
Secondly, endoscopy has a role to play in the digestive tract for the detection of small
lesions, mainly cancerous, and for the therapy. Endoscopy could be more suitable than
radiology in these fields. The tools for the detection of early stages of carcinoma are
the progresses in scope technology (processor, CCD, electronic zoom, thin endoscopes), the
development of cancer screening programs, the generalization of chromoscopy, the analysis
of risk markers on samplings (p53, gene abnormalities,_), the laser-induced fluorescence
spectroscopy and concerning EUS, the improvement of image resolution, the use of
high-frequency ultrasonic probes, and of the needle cytology puncture to eliminate
metastatic lymph nodes and recurrence.
Concerning therapeutic endoscopy, developments occur at a regular rate, parallel to the
developments of laparoscopic surgery. The principal fields are 1) hemostasis (argon
beamer, detachable snare, hemoclip, multiple band ligator, fibrin glue, cyanoacrylate,_),
2) treatment of benign stenosis (balloon dilation, corticosteroid injection, biodegradable
stents,_),
3) motility (injection of botulinum toxin, treatment of Zenker’s diverticulum,
antireflux procedures,_), 4) cancer palliation (self-expandable stents, celiac plexus
neurolysis,_) and
5) the promising endoscopic cancer cure (mucosectomy, photodynamic therapy, local
chemotherapy, microwave application and in the next future, local injection for gene
therapy and high-intensity focused ultrasound, _).
Finally, the place of the GI endoscopist himself is changing or has to change to face
challenges imposed by the other specialists. Depending on national specificities, the
endoscopist is purely a technician, an hepatograstroenterologist, an internist or a
combinaison of the three. At this moment, limiting its activity to that of specialized
technician is certainly not the way to go. GI endoscopists must retain the highest
clinical knowledge on digestive diseases to keep the decision concerning the patient care
management. Endoscopy must be considered not as a speciality per se but as a part of
hepatogastroenterology, and if possible one of its most active.
Thierry Ponchon, MD
Digestive Disease Department
Hospital E. Herriot - Lyon, France
Gastrointestinal Endoscopy in India
The role of fibreoptic endoscopy in the diagnosis and mana-gement of gastrointestinal
and pancreatobiliary disorders can not be overemphasized. Semi flexible endoscopes were
being used in India for many years prior to availability of the flexible ones since early
70’s. Presently nearly 1500 endoscopy centres are working in India of which 250 have
facilities available for Colonoscopy, ERCP and related therapeutic procedures as well and
many of them are non-government Institutions. Laser therapy, Endosonography and
Extracorporeal shock wave lithotripsy for biliary and pancreatic stones are also available
at some selected centres.
In India endoscopy is being done not only by Gastroenterologists but by Internists and
general surgeons as well. Even in surgical field many young and some senior surgeons are
actively taking up laparoscopic surgery and the number of such surgeries being performed
has seen a tremendous rise in recent years.
Society Activities
With a view to further the role of Interventional Gas-troenterology, Society of Gastrointestinal Endoscopy of India was formed in late 70’s which now boasts of 438 life members and three corporate members. The Annual Conference of the Society is held in association with Indian Society of Gastroenterology and Indian Association for the Study of Liver every year in different parts of the country. The endoscopy sessions include theme symposia, selected free papers & posters, how I do it sessions, guest lectures, oration and endoquiz. The Oration, named Poona Oration in memory of Prof. B.J. Vakil, has been delivered by many leading luminaries viz. Prof. Peter Cotton (USA), Prof. R. Fujita (Japan), Prof. Sydney Chung (Hon Kong) and Prof. David Carrlocke (USA) in the past. From this year another oration named SISCO-PENTAX ORATION is being started which will be delivered by an expert in endoscopy working in India.
Teaching/Training
Endoscopy workshops are the regular feature in India and nearly half a dozen are being organized every year and some of them has seen participation of many International experts like Prof. Claude Liguory, Prof. Tetsuo Yamakawa, Prof. N. Soehendra, Prof. J. Leung and Prof. Roy Cockell. The year 1997 shall see the begining of video workshops in different parts of the country and Society of Gastrointestinal Endoscopy of India shall like to invite National/International faculty members as coordinators. The recent guidelines of OMED educational committee has given a fillip to our effort in this regard and our Society shall take all necessary steps to procure the tapes from OMED for the video workshops. Some of our centres are already providing hands on training to our young colleagues. Some of our colleagues have also been participating as faculty member in International Endoscopy Workshops.
Journal
As a means for updating the knowledge of the members, our Society started newsletters in 1993 and later the "Tropical Gastroenterology" a quarterly indexed journal, was adopted as an official journal of the Society with an exclusive endoscopy section in it.
Instruments, Accessories/Spares
In India almost all the endoscopes being used are from Olympus, Pentax or Fujinon. Some
of our enterpreneurs are working hard to manufacture indigenous fibreoptic endo-scopes to
bring down the cost of such equipments but it will take sometime to achieve the
perfection. Many of our gas-troenterology colleagues are preparing their accessories,
stents, prosthesis, injectors and variceal band applicators etc. indigenously making them
much cheaper as compared to the well established brands. It is hoped that the cost of
these life saving instruments are reduced further with reduction/abolition of import duty
so that the management of Gastrointestinal and Pancreatobiliary ailments become affordable
to a common man.
With the keen interest shown by OMED in disseminating the knowledge of digestive endoscopy
throughout the World, there is vast scope and opportunity available for greater
interaction between Indian Endoscopists and International experts.
B.K. Agrawal, MD, DM, FICP
Vice-President Society of Gastrointestinal Endoscopy
Patna, India
Endoscopists of the world unite! No, this is not a left-wing rallying cry but an
invitation to attend the 6th United European Gastroenterology Week which will be held in
Birmingham, England from 18 to 23 October, 1997.
At the Birmingham meeting, as at previous UEGWs, endoscopy will be well represented –
not only during the core meeting (Mon-Wed, 20-22 October 1997) but also at the Endoscopy
Post-graduate Course (Thursday 23 October 1997).
The non-original part of the scientific part of the programme has been prepared by the
UEGF and Local Scientific Committees. The UEGF Committee includes representatives from the
"seven sisters" organizations within the Federation – including the
European Society for Gastrointestinal Endoscopy (ESGE). However, the Post-graduate Course
in Endoscopy is organized for the Federation by the ESGE, in conjunction with the
Endoscopy Section of the British Society of Gastroenterology (BSG).
Until now, the UEGWs have been targeted mainly at European participants. For the 1997
meeting, however, the UEGF Council and the Local Organising Committee have decided to go
world-wide. Therefore endoscopists, gastroenterologists and hepatologists form the
Americas (North and South), the Asian Pacific area and Africa – as well as those from
Europe – will be welcome in Birmingham.
Travel: Getting to Birmingham is surprisingly easy. The city has its own
International Airport which is only ten min away from the town centre (New Street
Station), by train. There are non-stop flights to Birmingham International Airport from
more than 20 European destinations – as well as from Chicago and New York.
Alternatively, for those who chose to fly into London, there are regular coach services to
Birmingham from Heathrow and Gatwick Airports, and fast (80-100 min) Intercity trains from
Euston Station in Central London, every 30-60 min.
The City: Forget any pre-conceived ideas you may have about Birmingham: in recent
years, it has been transformed into an exciting and stimulating city. In addition to its
magnificent new Symphony Hall (home of the City of Birmingham Symphony Orchestra and the
venue for both the Opening Ceremony on Sunday 19 October, and a public concert on Tuesday
21 October, 1997) and the nearby Repertory Theatre, it has excellent museums and art
galleries, wonderful jazz and interesting parks. What’s more, you can dine in a wide
range of restaurants serving international cuisine, at prices to suit all pockets.
The venue: The scientific meeting will take place in the state-of-the-art
International Conference Centre (which includes Symphony Hall) and at the nearby National
Indoor Arena, which is only 3-4 min away along a covered canal-side walk. The ICC and NIA
are in the centre of the city, within easy reach of New Street Railway Station and a
number of International hotels.
The core scientific programme: The Local and UEGF Scientific Committees have chosen
an interesting and up-to-date programme of symposia, overview and state-of-the-art
lectures on the latest developments in all aspects of our specialty. Where possible, the
subjects covered by the panellists and lectures will be linked to original presentations
on the same themes. As at previous UEGWs, there will be a number of Industry-sponsored
satellite meetings – as well as post-graduate courses and an endoscopy learning
corner. The core meeting runs from Monday 20 October to Wednesday 22 October, 1997
inclusive. It includes plenary, semi-plenary and parallel sessions offering a wide choice
of topics ranging from basic science, through endoscopy to clinical gastroenterology and
hepatology.
In addition to verbal presentations, posters will be displayed each day at the National
Indoor Arena and two hours of protected time will be devoted to lunch, poster viewing and
discussion sessions of selected posters. The commercial exhibition, poster display,
endoscopy learning corner and lunches will all be at the National Indoor Arena (the cost
of the boxed lunches is included with your registration fee).
Social programme and tourism: If time permits, we hope that you will take the
opportunity to explore the city and its surroundings. Birmingham is the capital of central
England and lies in the middle of beautiful countryside. You will find it easy to visit
Stratford-upon-Avon, birthplace of William Shake-speare, Warwick Castle, one of the finest
medieval castles in England, the Costswolds with its picture-postcard villages, and
Ironbridge – the cradle of the Industrial Revolution.
Our Local Organising Committee hopes that you will support the 6th UEGW – not only by
attending and encouraging your colleagues to do so but also by submitting abstracts of
your best original work. You will find the necessary abstract forms and instructions, in
this announcement.
We look forward to welcoming you in Birmingham during October 1997.
R. Hermon Dowling, MD
Chairman Local Organising Committee
President of BSG 1996/97
London, U.K.
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