World News in Digestive Endoscopy
Issue 7, October 1997
The Acting President of OMED 1997-1998
Last May, at the Assembly and Governing Council held at the DDW,
Professor Massimo Crespi was elected acting President of the OMED.
Professor Crespi is well known world wide in the field of Gastroenterology and Digestive
Endoscopy.
It is a great pleasure and honour for me to annunce his nomination because not only is he
a dear friend but Ihave had also the opportunity of collaborating with him for many years.
Professor Crespi graduated in Medicine in 1959 at the University of Rome.He is Professor
of Gastrointestinal Endoscopy at the Post-graduate School of Gastroenterology at Rome
University "La Sapienza".
At present he is Director of the Department of Enviromental Cancerogenesis, Epidemiology
and Prevention of the Regina Elena Institute in Rome and Head of the Gastroenterology
Section. He is Director of the Italian Section of the WHO Collaborating Center for Stomach
Cancer.
Professor Crespi was Secretary General and Past President of the European Society of
Gastro-Intestinal Endoscopy (ESGE) - Past Chairman of the United European Gastroenterology
Federation (UEGF) and he will be the Chairman of the United European Gastroenterology Week
(UEGW) in Rome 1999.
He is an active member of numerous Gastroenterological Societies and International
Academies and he is also in he Editorial Board of many scientific Journals such as:
Endoscopy, Digestive Endoscopy (Japan) and Scandinavian Journal of Gastroenterology.
Author of 220 scientific paper regarding Gastro-Intestinal topics.
Personally it is a great satisfaction for me to witness this mile stone in his outstanding
career and the OMED will certainly benefit under his leadership.
Alberto Montori, MD, FACS
OMED Treasurer
Having trained at a time when the majority of endoscopy was diagnostic
and therapy was limited to polypectomy and guidewire passage to facilitate esophageal
dilation, I am struck by the changes that have occurred in endoscopic practice over the
past 20 years. On the one hand, we have evolved from a diagnostic to a therapeutic
discipline. Today, biliary and even pancreatic stone retrieval are commonplace; bleeding
lesions are treated with a variety of thermal, injection, and banding techniques; and a
multitude of benign and malignant stenoses are fair gamefor various endoscopic maneuvers.
These include dilation, thermal- or photoablation, and palliation using rigid or
expandable prostheses.
These changes in practice patterns both preceded and followed evolutions in technology. In
some instances, particularly with regards to endoscopic accessories, technology evolved to
fill perceived needs. The latter included contact thermal devices to stop gastrointestinal
bleeding and many of the accessories now used to facilitate retrieval of common bile duct
stones. In other instances, technology, which had been developed for other situations, was
incorporated into endoscopic practice. Witness the incorporation of the Charged Couple
Device (CCD) chip into the end of a tube which resembled a fiberoptic endoscope in form
only. Not only did the latter revolutionize the way images were generated, but in
conjunction with a computer interface, the way in which they could be enhanced and stored.
Such technology also dramatically improved one’s ability to interact with
gastrointestinal nurses and assistants and to train our students and colleagues.
Two other changes have helped to revolutionize endoscopic practice in the last 20 years:
an improved understanding of gastrointestinal physiology and pathology and the
globalization of medical education. Witness changes in endoscopic practice that have
occurred since Helicobacter pyloridis was found to be etiologic in most cases of peptic
ulcer disease and the recognition that variable degrees of dysplasia precede the
development of invasive cancer in patients with Barrett’s esophagus and inflammatory
bowel disease, respectively. From the latter standpoint, the rapid dissemination of
knowledge in the form of journals and textbooks, continuing medical education courses, and
audio or videotapes are simply the tip of the information-transfer iceberg. Our ability to
digitize text and static as well as moving images not only allows information transfer
with CD-ROM and the Internet, but emerging technologies such as the visual Digital Disc
(DVD).
Concomitant with the above-mentioned evolutions has been an evolution in the medical
societies that represent us locally, nationally, or internationally. Such societies are
often the post-graduate glue that hold a profession together offering both medical
education and resources for endoscopic research. They variably offer assistance with
practice management, add political clout for the profession and may define training and
practice guidelines which assure practice excellence. The American Society for
Gastrointestinal Endoscopy (ASGE) evolved from the American Gastroscopic Club which was
founded in 1941. Started by a group of internists enamored by glimpses of the esophagus
and proximal stomach gleaned through rigid esophagoscopes, this "club" now
approximates over 6,500 members. Under its auspices, endoscopists engage in all of the
societal functions mentioned
above; however two functions have importance and deserve
particular mention insofar as international endoscopy is concerned. On the one hand, the
Society publishes Gastrointestinal Endoscopy. With a circulation approximating
10,000 and upcoming publication on the Web, this journal has become the premier
international venue of endoscopic research and original endoscopic articles. And not only
have 50 new international endoscopists been named to the Editorial Board, but fully
one-half of original articles originate outside the United States.
The second item of importance to the international endoscopy community are its educational
endeavors. These include not only the yearly Digestive Disease Week®, ASGE post-graduate
course attended by over 2000 endoscopists from around the world, but the ASGE Learning
Center. The latter composed of slide sets, CD-ROMs dealing with endoscopic technique and
pathology, and over 40 state-of-the-art endoscopic videotapes is updated and shown yearly
at DDW® and portions of it have been/will be made available to the Swiss, German,
Egyptian, Venezuelan, and Pan American endoscopy societies. It will be available in its
entirety in Vienna next year to support OMED and the World Congresses of Gastroenterology.
Moreover, as part of an international commitment to education, the ASGE has recently
partnered with Boston Scientific (Microvasive Inc.) to reformat these tapes into PAL as
well as VHS formats and to produce new tapes. Many of these will be available for purchase
in Vienna in 1998. Additional Societal commitments to world-wide endoscopy included
co-sponsoring the Spanish Society for Digestive Endoscopy and Digestive Pathology’s
Annual Post-Graduate Course in Madrid last June as well as an upcoming meeting in Italy in
1998.
Additional international educational sponsorships are currently being evaluated and may
consist of sending Societal speakers, use of segments of our 1996 and 1997 Post-graduate
Course, or participation in a limited number of live courses. From a club of intimates to
a parochial, and now an international society, the ASGE recognizes and salutes the
excellence in endoscopy that has developed world-wide and would welcome qualified
individuals throughout the world to our International Membership.
It has been a mere 20 years since I finished my endoscopic training, yet the evolution in
technology, training, understanding and treatment have revolutionized endoscopic practice.
Our societies, in turn, have had a similar evolution and with the aid of rapidly-evolving
post-graduate training techniques and a commitment to maintaining endoscopic excellence,
offer fellowship, support, and education in Vienna and beyond. The ASGE salutes and
supports OMED in this endeavor.
Richard A. Kozarek, MD
ASGE, President
Endoscopy at the 5th UEGW, Paris 1996
The United European Gastroenterology Week held its 5th meeting in Paris
in 1996 (November 2-6). The sustained success of the annual event was confirmed by a large
assistance: registrations amounted to 8,477 including 556 nurses from the ESGENA meeting
and registrants came from 92 countries. Comparing to UEGW 95 in Berlin, the increased
participation concerned the Northen (+39%), Southern (+56%) and Eastern (+42%) European
sectors. The annual meeting is organized by seven European sister societies, one of which
is the European Society of Gastrointestinal Endoscopy (ESGE).
In 1996, in Paris, the C.N.I.T. Convention Center offers all facilities and, thanks to the
Professional Congress Organiser SOCFI, everything went well. The program has been
established according to the code of practice of the United European Gastroenterology
Federation (UEGF), with the cooperation of a Scientific Committee issued from the seven
societies.
The congress went on during 5 days – Saturday and Sunday for post-graduate courses
– Monday to Wednesday for the meeting proper. In this core section, according to the
UEGF practice, each of the parallel sessions involved a mixed program, alterning –
symposia and thematic original sessions – clinical data and basic research. The
objective was to encourage communication between subspecialties. Therefore endoscopy was
present everyday, either in specific sessions or clinical topics including endoscopy,
gastroenterology, hepatology, surgery. Two pediatric sessions on endoscopy were also
programmed. Endoscopic sessions were indeed particularly active and well attend; therefore
a strong part of the joint meeting. The success is due to the active participation of Jean
François Rey (ESGE member of the Scientific Committee). Registrants could easily find
their way across the dense pocket UEGW program in the section "passport to the core
meeting", where a specific section entitled "endoscopy and radiology" was
printed.
At the ESGE post-graduate course, during 2 days (Nov. 2-3), the attendance varied from 600
to 800. The course incluted a live demonstration session transmitted from the A. Tzank
hospital near Nice on Saturday, supported by a generous educational grant from the Olympus
Co. The academic course on medical and legal aspects of complications during endoscopy was
held on Sunday. ESGE awards were attributed to D. Wilson (Wilson Cook Co.) and I. Kawahara
(Olympus Co.) as a token of the excellent cooperation with the biomedical engineering.
During the core meeting, two symposium were officially sponsored by ESGE: – Use and
abuse of endoscopy – Sedation adapted to endoscopy. Major sessions (symposium), with
more or less endoscopy were: – hints on intestinal bleeding with an audience
over 1,000 – metal expandable stents – new imaging procedures in the exploration
of the pancreas and bile ducts – new aspects in clinical laser lithotripsy –
virtual colonoscopy – early detection of colorectal cancer. Two Forum on pediatric
endoscopy were sponsored by the European Society for Paediatric Gastroenterology and
Nutrition (ESPGAN). While few thematic sessions (selected original communications) were
specifically devoted to endoscopy, the contribution of endoscopic or other imaging
procedures appeared in the mixed content of various sessions. As an example, 4 out of 12
communications selected for the plenary session belonged to this sector. Similarly 19 out
of 70 posters in the permanent section concerned diagnostic and interventional endoscopic
or radiologic procedures. The thematized posters sessions included subsections on
biomedical technology, stomach endoscopy, variceal bleeding, diagnosis of colonic
diseases, colonoscopy, biliary tract imaging, interventional biliary procedures.
Video sessions were a hit: the 6 ESGE sessions, had a compressed audience (around 200) in
small room. Endoscopic videotapes were presented on esophagogastroscopy, enteroscopy,
colonoscopy, cholangiography, pancreatography, ultrasonography. In the exhibition area the
large demonstration stands of the biomedical industry had a large affluence. In this area,
the ESGE Computer video Corner offered from Monday to Wednesday (10.00 am to 5.30 pm), the
following events based on video tapes: meet an expert session, teaching encyclopedy, ESGE
internet access, Quizzes, demonstration stands. Last but not least, ESGE participated
actively in the program held by European Society of Gastroenterology and Endoscopy Nurses
and Associates (ESGENA).
R. Lambert, MD
Chairman 5th UEGW, Paris, 1996
Endoscopic Mucosal Resection for Early Gastric Cancer
Endoscopic treatment is employed routinely in clinical practice
throughout Japan for the curative treatment of early mucosal gastric cancer. The forms of
endoscopic treatment can be classified into non mucosal resection and mucosal resection.
Laser treatment is a typical method for non mucosal resection, however it cannot remove
the lesion. On the other hand, the mucosal resection using the high frequency electric
current makes it possible to confirm histopathologically the complete curability of
resected and collected lesions. Of the high frequency electric current methods, there are
two chief methods, polypectomy and endoscopic mucosal resection (EMR). Although
polypectomy is indicated to only the lesion with stalk, EMR is indicated to not only the
protruding lesion without stalk but also to flat and depressed lesion.
With the recent progress in endoscopic diagnosis, the discovery of early gastric cancer
with less malignant appearance such as faint redness, discoloration, and/or unevenness of
mucosa, or small size (less than 10 mm) has increased markedly. Out of 197 cases of early
gastric cancer obtained in 1996 at our hospital, the
incidences of early-gastric cancer with less malignant
appearance and small size were 51% and 20%, respectively. For the patients with small
gastric cancer, EMR has been positively performed as an alternative to gastric resection.
The ratio of EMR to surgery for early gastric cancer has increased yearly in our hospital
as shown in figure 1. In addition, quality of life and performance status are not
disturbed and hospital stay and cost are reduced in the patients recieving EMR compared to
surgery. Therefore, EMR for early gastric cancer has recently become the treatment of
choice for lesions, even in patients without surgical risk.
The EMR was developed in 1980 and first performed for early gastric cancer in 1985 by Tada
et al (1). The principle of EMR is based on the combination of endoscopic injection and
polypectomy. After marking around the target lesion, 20 to 40 mls of saline - epinephrine
solution are injected endoscopically into the submucosa near the target lesion, until a
protruted shape is formed. Then, forceps are placed over the protruted lesion and its base
is snared and excised by high frequency electric current. The injection of saline -
epinephrine solution maintains the distance between the mucosal layer and the proper
muscle layer, and thus prevents damages to the deeper layer by high frequency electric
current. Details of the EMR method are illustrated in figure 2. Besides this method, there
are the following 4 methods; the hood method, EMRC (Endoscopic Mucosal Resection using
Cap-Fitted Pan-Endoscope) method, EAM (Endoscopic Aspiration Mucosectomy) method, EMR-L
(EMR with ligating device) method, and fixing four points method (2).
The indication to curative EMR for early gastric cancer should be limited to the lesion
without lymph node metastasis. In our hospital and other institutions in Japan, many cases
of early gastric cancer have been treated surgically and studied pathologically. According
to these studies on lymph node metastasis, the existence of metastasis was closely related
to the depth of cancerous invasion, its macroscopic type whith is in accordance with the
classification of the Japanese Gastroenterological Endoscopy Society and its size. At
present, basically, our indications include 1) intestinal type, 2) mucosal cancer not
invasing the submucosa, 3) protruding lesion (type I and IIa) with a largest dimension of
up to 20 mm and 4) flat (type IIb) and depressed (type IIc without ulcerative change)
lesion up to 10-15 mm in diameter. However, efforts have been made to extend the
indications to curative EMR for early gastric cancer. We reexamined histologically the
surgically resected specimen of solitary early gastric cancer operated from 1962 to 1991
at our hospital (3). No lymph node metastasis was found in 88 cases of IIa type intestinal
mucosal cancer. IIa type of intestinal submucosal cancer had 25,7% (9/35 cases) of lymph
node metastasis. In 374 cases of IIc type of intestinal mucosal cancer, 3 cases had lymph
node metastasis (0,8%). The maximun diameters of the three lesions with lymph node
metastasis were 28, 32 and 46 mm, respectively. Thirty-one out of 252 cases (12,3%) of IIc
type intestinal submucosal cancer had lymph node metastasis. Furthermore, there was no
difference in the rate of lymph node metastasis between lesions with ulcerative change and
ones without ulcerative change. This study revealed that the rate of lymph node metastasis
of all IIa and IIc type intestinal mucosal gastric cancers, regardless of their maximum
diameter and ulcerative findings, was extremely low. Practically, however, the larger IIc
type intestinal cancers have submucosal invasion more frequently. More than a half of
lesions, of which maximum diameter is over 30 mm, have submucosal invasion. In conclusion,
it is suggested that the IIa and IIc type intestinal mucosal cancers of which maximum
diameter is up to 30 mm are indicated to EMR. It is proper that the piecemeal resection is
needed for the larger lesion (Fig. 3). Unless the whole lesion is resected in one piece,
we should be careful as it becomes more difficult to evaluate definitely whether the
lesion is completely resected or not. In addition, the feasibility of extending the
indications to include a diffuse type and the lesion with very small quantity of
submucosal invasion are also under condition.
Evaluation of therapeutic effect is based on the resected specimens, as in the case of
conventional surgery. In the case of complete resection, the patients are followed up
endoscopically including biopsy every 3 months in the initial year and every 6 months in
the 2nd year after treatment. After that, the patients are followed up annually. If
recurrent or new lesions are recognized during the follow-up, the surgical resection
should be performed. The complete resection rate is 60% (263/438) in our hospital, because
of the limitation of accurate endoscopic diagnosis for vertical cancerous invasion, even
using the endoscopic ultrasonography, and the technical difficulty due to the location of
lesion. Although it is possible that the endoscopic treatment, EMR or laser irradication,
is added to the incompletly resected lesion, the surgical operation should be performed.
Besides the incomplete outcome, there is few frequency of accidents such as hemmorage and
perforation as the demerit of EMR. When the EMR was initially performed for early gastric
cancer, the emergency surgical treatment was essential for the patients with these
accidents. In recent years, however, even if perforation does occur, we try the
conservative endoscopic treatment using clips as shown in figure 4. To avoid these
accidents, the development of better endoscopic instruments is needed in addition to the
improvement of resecting procedures. Recently, we developed a new endoscopic
insulation-tipped diathermic knife (IT knife) (4). The It knife has a small ceramic ball
at the tip of the diathermic needle knife to prevent a vertically deeper burn toward the
proper muscle layer and eanable the resection of a larger lesion in one piece. The figure
5 shows the case treated EMR using an IT knife.
The radical EMR for early gastric cancer is an ideal treatment of minimal invasion.
However, there may be a few accidents, so that the skilful endoscopist, the cooperation
with surgeon and the informed consent for the patient beforehand are needed.
Daizo Saito, MD
Endoscopy Division, National Cancer Hospital
Tokyo, Japan
References
Standardization in Digestive Endoscopy: Why? What? How?
The fast advances made over the last decade in the field of personal
computers (PC) and the development of videoendoscopes over the same period have open the
way for new applications in digestive endoscopy. Their goal is primarily to improve the
communication of data between users of endoscopy systems. Circulation of data will benefit
to patient care but also to education, both primary and post-graduate and training, as
well as it will finally results in cost savings and in a better management of digestive
diseases. Since videoendoscopes have been available quite recently, the interest of
gastro-enterologists for such questions has been raised over the last few years. However,
this activity of standardization and exchange of medical data is ongoing since many years
in other fields like radiology.
Why do we need to standardize endoscopic data? Standardization supposes that information
will be produced in a common way by different operating systems. This means that each of
these systems will be able not only to export objects in the standard format but also to
import them without altering their intrinsic quality. There are many reasons for promoting
standardization of endoscopic data. In clinical practice, diagnosis and therapeutic
decisions are more and more based on the results of various procedures, including
endoscopy. The patient’s folder contains thus a number of images and data that need
to be properly archieved, stored and retrieved. The idea of using computers for this
purpose is not new but all attempts to create large systems encompassing all the data
related to one patient have so far failed. The electronic health record remains an
unsolved problem. By contrast, information systems limited to one or some modalities of
investigation of the patient may offer adequate services in many cases. So, radiology
information systems are now offered by manufacturers together with their equipments. There
is a need for equivalent systems in endoscopy. The solutions offered by the manufacturers
should be independent of their workstations and interoperability should be ensured.
Therefore we need standardization of data formats. Starting from this, the material
produced and easily accessible will promote:
What do we need to standardize? Endoscopic data comprise images and
text, containing a number of data (Tab. 1). These data include patient, procedure and
findings/diagnosis-related items. Images are now part of the endoscopic reports although
most of them do not contain images so far because including images into the report
requires either expensive or technically adavanced solutions. Endoscopic images are
characterized by their colour frame and usually the presence of multiple lesions on them.
Moreover, not all the information gained from an endoscopic procedure is documented with
images. This means that the report has a key function in the transmission of information.
Contrary to radiologists, gastroenterologists have first concentrated on the
standardization of terms describing the endoscopic findings. In this field, OMED has
promoted standardization far before most of other organizations, with the tremendous work
done by Professor Z. Mar?atka during decades in the Terminology Committee. But an endoscopic report also
contains data on the reasons why an examination was performed, on the final diagnosis and
recommendations made by the endoscopist at the end of the procedure to the referral
physician… Therefore, the need for a revised version of an endoscopic thesaurus
became obvious over the last five years.
On the other hand, the fastly broadening use of electronic images has imposed the use of
standards for exchange of images. Some exchange formats are becoming standards de facto
because they are used by huge and powerful organisations mastering the information
technology. These image formats (JPEG, TIFF, TGA, EPSF, GIF…) are not only used in
medical applications and the medical field is a too restricted market to impose an
additional and specific format. However, exchange of medical images has some specific
requirements. To meet these requirements, the efforts of the American College of
Radiologists and of the National Electric Manufacturers Association have resulted in the
production of a common transfer protocol that allows the systems to exchange data. This
system has been named the DICOM (Digital Images Interchange and Communication in
Medicine). From its initial basis in radiology, the DICOM has expanded to endoscopy and
now to all visible light modalities producing images: dentistry, ophthalmology,
pathology… One must well understand that the DICOM is not an image format by itself
but rather a shell which allows the acceptor systems to recognise all the informations
contained in an object because these data have been organized in a structured way by the
sending system and because these systems are able to recognize this structure.
How can we standardize the endoscopic data? To standardize text data, we need to use
thesauri and vocabularies that organize the various diseases and endoscopic findings in
common terms. There is a number of these vocabularies based on the international
classification of diseases (ICD-9 and ICD-10), on pathology findings (SNOMED) or
aggregating various vocabularies (UNMLS of the National Library of Medicine in the USA).
As said before OMED promoted standards terms for endoscopy in the past. This effort was a
real pioneer action. However, it did not take into account the various elements of an
endoscopic reports and the terminology proposed suffered of being too detailed and
offering many double entries (redundant terms) describing one unique lesion, e.g.
malignant stenosis versus stenosing tumour. Starting from the definitions proposed by the
OMED terminology, the group of experts committed by the European Society for
Gastrointestinal Endoscopy (ESGE) proposed a "Minimal Standard Terminology"
of about 150 terms that covers 95 % of endoscopy procedures. It contains lists of terms
for oesogastro-duodenoscopy, colonoscopy and ERCP, arranged by main locations (oesophagus,
stomach, duodenum, colon…) and describing the reasons for performing an endoscopy,
the endoscopic findings, each term being specified by the use of various attributes and
the endoscopic diagnosis, made at the end of the procedure. This "Minimal Standard
Terminology" meets the criteria of a practical use in computerized databases and
allows the transfer of data between systems.
Transfer of images should be based upon the Visible Light supplement of the DICOM. This
supplement uses the main features of the DICOM 3.0 exchange protocol for radiology images
plus a number of items specifically needed to describe the colour frame of the endoscopy
picture. We must succeed in achieving a committment of all manufacturers of endoscopic
workstations to provide systems which will be DICOM-compliant. But we must recognize that
endoscopy is far from reaching such an integration. It will be possible only if users and
producers combine their efforts.
To be effective, standardization must allow the circulation of the whole information
obtained during an endoscopic procedure. This information includes the images and the
surrounding information. There is currently no standard organizing this type of composite
objects. The structure of object-oriented databases is perfectly adapted to this purpose
but they use different format. Therefore the ESGE has initiated a research project that
has been funded by the European Commission and which is intended to integrate text and
images in objects based on the DICOM format and using the "Minimal Standard
Terminology" for description of the content. The Gaster project will also produce
a database of referenced endoscopic images that will be used later on for education and
for supporting the promotion and the dissemination of these standard protocols (Fig. 1).
Similar actions are funded by the NIH in the USA. All these efforts will certainly meet
and merge into the action launched by the DICOM Organisation for building of a
"Structured Report" module to be added to the DICOM format. Creating a common
frame for structuring medical reports would be a major advance for the actual use of
standards in daily practice. However, standards will be used by the community only when
their use will become transparent to the common user. When you call a Australian friend on
the phone from Europe, you don’t care about the interoperability of telecommunication
systems between the two countries. However the fair process of the call is based on the
standards used by the various operators to link their networks. This is the goal of all
the people involved in this research and definition work around the DICOM. As
practitioners, we must participate actively in order to secure that developed standards
will actually meet the criteria of a fair clinical practice.
MDelvaux, MD
Coordinator of the Gaster Proyect, CHU Rangueil Toulose, France
JR Armengol-Miró, MD
Vice-President OMED - Hospital Valle d’Hebron Barcelona, Spain
MCrespi, MD Chairman, ESGE
Committee for Minimal Standards, Istituto Regina Elena - Rome, Italy
The World Organization of Digestive Endoscopy represents organized
gastrointestinal endoscopy throughout the world. Many areas of the world are well-served
by endoscopic societies, endoscopic organizations, and gastroenterology associations which
have active endoscopic components. Each of the many endoscopic organizations throughout
the world are autonomous, and most endoscopic organizations or groups of endoscopists
develop their own rules, regulations, and organizational structures to suit their
particular needs, constituents, and geographic areas. For the most part, rules,
regulations, endoscopic guidelines, and organizational structures are developed
independently from any other endoscopic organizations. Associations which are well
established and have multitudes of members are the groups that characteristically take the
lead in the development of practice parameters, practice guidelines, and in the defining
of indications, techniques and contraindications for gastrointestinal endocopy. omed has
taken upon itself the collation of information from various sources throughout the world
and has redefined itself as being the stucture which scan knit the various worldwide
organizations into a cohesive array of societies. OMED is the link across all of endoscopy
and will disseminate knowledge and education to all of our members, from the highly
organized societies to te less-well-developed groups of endoscopists throughout the world.
In an attempt to transmit specific knowledge about endoscopy, OMED has made available the
endoscopy videotapes from the last two World Congress of Gastroenterology to any
member-constituent GI organization throughout the world. These are available in both PAL
and NTSC format, and merely have to be requested by the constituent societies. The intent
of OMED is to have these shown at any endoscopic congress held by the individual society,
or available to be loaned to any individual or group in that society. Any individual may
purchase the entire twelve-videotape packet of World Congress videotapes from the
endoscopy courses of the Australia World Congress of Gastroenterology (1990) as well as
from the Los Angeles World Congress of Gastroenterology (1994) for US$100 plus mailing.
These can be obtained by sending a check directly to:
- Massimo Crespi, MD - OMED acting president.
The Education Committee has also requested information on constitutions and by-laws from
all of the constituent endoscopic r in worldwide endoscopy education. Please send in
suggestions and comments concerning educational endeavours in the field of
gastrointestinal endoscopy.
Jerome D. Waye, MD
Chairman, OMED Education Committee
New York, U.S.A
OMED Research Committee: Meeting Minutes, Washington DC, May 11 1997
Present:
Eamonn Quigley (USA, Chair), René Lambert (France), JF Riemann (Germany), The-Hong Wang (Taiwan), Massimo Crespi (Italy, General Secretary-OMED), Alberto Montori (Italy, Treasurer-OMED)
Item #1
Consideration of research proposal submitted by Dr. Al Svoboda, "The International Cooperative Study on Intestinal Metaplasia/Dysplasia at the Gastroesophageal Junction". This protocol was considered in detail. The committee had some persisting concerns regarding the revised protocol, which was available for review. Particular concerns related to the lack of ethnic variation between the study centers. Though the study proposed to look at factors, including racial and ethnic factors, which might influence the prevalence of these disorders, the study as proposed was limited in ethnic variation. The committee proposed extending the study to include more centers in Europe (Dr. Lambert and Riemann both offered to provide data) and centers in Asia, and it was proposed that the principal investigator should contact Dr. Sidney Chung in Hong Kong, and Dr. Wang proposed contacting the National Taiwan University Hospital for their involvement. Study sites in Latin America were also proposed, and the group suggested contacting the investigators at the Hospital Das Clinicas in Porto Allegre in Brazil who have a particular interest in esophageal disease. The group also proposed contacting Dr. Ben Kahlifa in Tunisia as an African center. It was also proposed that Dr. Svoboda should pursue discussions with Dr. Fraumeni at NIH regarding study design, and that he should also modify the questionnaire to include a discussion of prior antisecretory therapy. It was concluded that subject to the inclusion of further sites to reflect greater ethnic variation, modification of the questionnaire and the pursuit of further discussions with Dr. Fraumeni, the protocol will be approved for funding.
Item #2
Database on endoscopic priorities. Dr. Quigley introduced this topic. It
is quite clear that endoscopy has a very different role in different parts of the world -
most of our colleagues are not aware of this, however. If OMED is to be a voice for
endoscopy and endoscopic research in the future, Dr. Quigley felt it was important to have
data on hand to indicate what are the most important priorities for the development of
endoscopy in the various parts of the world. Dr. Quigley proposed the development of a
database on the most important diagnostic and therapeutic uses of endoscopy in various
parts of the world.
In discussion, it was concluded that a questionnaire should be developed and sent to
endoscopy societies throughout the world. Each endoscopy society would, in turn, submit
this questionnaire to ten selected endoscopists in their membership who would respond to
questions on the following are areas:
It was also felt that input should be sought from the EASGE, SIED and the Asian Pacific Society. Dr. Quigley was instructed to coordinate with Dr. Jerry Waye, Chair of the Education Committee of OMED, regarding a combined presentation with the Education Committee at the World Congress in Vienna.
Item #3
Dr. Quigley discussed the development of a working party to develop guidelines for minimal standards in endoscopic disinfection. This working party has been developed under the auspices of OMED, and will present its findings at the World Congress. In discussion, a number of committee members pointed out the potential hazards of the development of "minimal standards". In particular, if these standards fell below those which had been generated by a national endoscopy or gastroenterology society, they could be used as evidence "against" the national society and in favor of a relaxation of standards in that country. Dr. Quigley promised to bear this point in mind in further discussions with the working party. Professor Crespi introduced the concept of developing minimal standards for equipment and physical plant endoscopy. This should form the basis for a future study.
Item #4
Professor Riemann introduced the topic of outcome studies in endoscopy. Extensive discussion took place in this area, and it was generally agreed that there was an important role for outcome studies to evaluate the role of endoscopy in a variety of clinical settings. As a consequence of these discussions, the following allocation of topics was agreed:
Item #5
Dr. Quigley thanked the committee members for their attendance and their
active participation in the committee meeting.
There being no further business, the meeting was adjourned.
Yours sincerely,
Eamonn M.M. Quigley, MD, FRCP, FACG
Chairman, OMED Research Committee
University of Nebraska, U.S.A.
Endoscopy Training in The Philippines
Background
Digestive endoscopy has been practiced in the Philippines for around 50
years with the first gastroscopy in 1948. Records regarding the expertise and the
practices of these early practitioners are not available because the exchange of
information then was done mostly on an inter-hospital basis. What is definite is that in
the 1960’s, Endoscopy was performed with rigid and semi-flexible endoscopes.
The organization of the Philippine Society of Gastroenterology (PSGE) in 1960, the
Asia-Pacific Society of Digestive Endoscopy (APSDE) in 1973, which has several Filipino
members, and the Philippine Socety of Digestive Endoscopy (PSDE) in 1976 hastened the
growth and progress of endoscopy in the country. Furthermore, rapid developments in fiber
optics encouraged some hospitals to acquire endoscopic instruments and establish the first
units.
By the early ‘80’s, hospitals mostly in Metro Manila had established their
teaching programs in Endoscopy.
Training Requirements
Since its founding, the APSDE, along with other known institutions in
Asia, has had a marked influence in the establishment of endoscopic centers in Southeast
Asia. The Philippines is among the beneficiaries of their efforts to further the interest
of endoscopy.
In our country, the advancement of specialized training in endoscopy started with the
organization by the PSGE and the PSDE of a Specialty Board tasked to certify Diplomates in
Gastroenterology. Thus, since the establishment of the Board, family physicians/general
practitioners have no longer been allowed to practice endoscopy which is only for those
who trained in accredited institutions duly certified by the Board.
Throughout the country, there are 14 accredited institutions that offer the 2-year
training program in gastroenterology encompassing endoscopy. Six (6) are affiliated with
medical schools.
An applicant must complete the three-year residency in internal medicine prior to
admission to the Gastroenterology Diplomate. After the two-year program, the trainee must
hurdle the specialty examination by the Board. Some of the teaching institutions require
trainees to practice where gastroenterologists are scarce or join the academe in other
Philippine regions where there are medical schools.
Training centers accept a fixed number of trainees based on a quota set by the PSGE and
the PSDE in accordance with the centers’ facilities and teaching materials. These
teaching institutions are inspected regularly to ensure compliance of all requirements.
Training Practices
Once accepted, trainees undergo preceptorial programs in diagnostic and
therapeutic endoscopy supervised by certified diplomates. Their assignments are on a
rotation basis as they participate in patient care, teaching, and research activities. The
period of time devoted to endoscopy is set by the training institution to determine the
trainees’ ability to observe and perform the required procedures either independently
or supervised by a consultant.
Endoscopic procedures now available in teaching institutions are:
esopha-gogastro-duodenoscopy; sclerotherapy; esophageal dilatation endoprosthesis;
variceal banding; foreign body extraction; heater probe application; non-variceal
injection; PEG; ERCP (sphincterotomy, stenting, balloon dilatation, hydraulic lithotripsy,
and nasobiliary drainage); colonoscopy; fibersigmoidoscopy; polypectomy; and occasionally
peritoneoscopy. Laparoscopy is covered by the training program for surgeons. Majority of
the training centers use the Olympus trademark with video facilities.
Most of the diagnostic upper GI procedures are without sedation. However, therapeutic
procedures for the Upper GI; in ERCP; and colonoscopy are done with conscious sedation.
Anesthesiologists are rarely called upon to assist.
There are 120 diplomates unevenly distributed throughout the country. Last year, they
performed approximately 12,500 to 15,000 endoscopies; 8,500 to 10,000 for Upper GI; 2,500
to 3,000 colonoscopies; and 1,000 to 1,300 ERCP’s.
Those who cannot be accommodated in Philippine training institutions may train abroad but
only under a recognized program. Some internists and surgeons have taken this option.
Those trained abroad are allowed to practice endoscopy but are not accorded the title
Diplomate in Gastroenterology unless they had passed the Philippine Specialty Board
examination.
The Future of Endoscopic Training
A major factor that has hindered the speedy development of endoscopy in
the Philippines is the high cost of acquiring and maintaining equipment. Hence, only a few
institutions are qualified to train.
Filipino doctors are, however, hopeful that with sufficient governmental and more private
support, more hospitals in other regions of the country would be able to acquire
state-of-the-art equipment for the training in gastroenterology. An increase in the number
of training centers would advance the practice of endoscopy in the Philippines.
Meanwhile, Filipino endoscopists keep abreast with the latest endoscopic procedures
through workshops and live demonstrations offered by training institutions.
Together with the national organizations, the teaching institutions hold scientific
conferences that facilitate the exchange of information. Several internationally-known
experts in digestive endoscopy have been invited to these workshops. Filipino endoscopists
acknowledge the contributions of these experts in enhancing the standards of the practice
of endoscopy in the Philippines.
All in all, the practice of endoscopy in the Philippines has become more promising and
challenging in this decade.
Jesus Y. Perez jr., MD
Dean St. Luke’s College Dept Medicine William H. Quasha Memorial
Quezon City, Philippines
Tumours of the large bowel have an increasing tendency all over the
world. In the Czech Republic there is now a threefold incidence on two fold mortality due
to this disease in comparison with incidence and mortality in 1960 (1). Tumours of the
large bowel are going to occupy the first place among tumours and calculating the number
of citizens the most important place in the world. There is a high occurrence of
colorectal cancer (CRC) in middle and eastern Europe and also in USA. Here about 150.000
newly diagnosed tumours on the large bowel are expected in 1997 and 55.000 death for the
same reason (2). The incidence of colorectal tumours is somewhat lower in Mexico and
south-eastern Asia.
There is a higher risk of CRC in families with polyposis, in patients with adenomatous
polyps, after curative resection for CRC, also in inflammatory bowel disease (extensive
ulcerative colitis, in Crohn disease with long lasting activity an onset at younger age).
This occurs also in Lynch syndromes I. and II. With higher familial aggregation of
digestive tract and other organs cancer. However these situations represents only a minor
part of CRC (3, 4).
The standart risk in the current population increases in the 5th decade and rises with
age. A generally accepted risk is the high fat intake, lack of fruits and vegetables
providing minerals, vitamins and fibers. An additional factor may be lack of physical
activity and a resulting tendency for obstipation.
According to this primary prevention is rather difficult and results may
appear after consideraly long-time.
Secondary prevention may occur after a much shorter time and may have an important
impact on CRC mortality. This seems to be particularly due to search for early stages of
CRC in asymptomatic individuals and surveillance of family members with increased cancer
risks (as mentioned above).
A fundamental basis is the selection precancerous conditions and CRC at a curative stage.
Certain biochemical, immunological and genetic testing is now being studied in various
centers, however non of them is suitable for current clinical praxis (5). The most
reliable evidence can be obtained from the FOB-test and from colonoscopy (6). The FOB-test
should be sufficiently sensitive, easy to perform and permanently good quality. Another
important factor is its price to prove cost-effectivness in positive cases. It should be
demonstrated that treatment of advanced cancer is more expensive than prevention. Personal
worry and troblesome end of life with an unresectable tumour can never be expressed
reliably in financial terms. Loss of productivity of the patient in the 4th-7th decade of
life should also be calculated. At present FOB-test are available at relatively acceptable
prices. However, for use in the whole population over 45 years this may represent
considerably cost for state. An economically strong state as the Federative German
Republic pays for an annual FOB-test in full; however, this offer was used paradoxically
only by 25% of women and 15% of men. Here it should be remembered that the price of
Heamoccult (FOB-test) is about the same as that of one cigarette box. Thus, every citizen
is economically able to pay for the FOB-test himself. In positive cases endoscopy is
mandatory. In various centers sigmoidoscopy is recommended in view of the fact that most
tumours are at a 65 cm distance from the anus (7). In the Czech Republic, however,
colonoscopic examination was proposed strongly and if possible - with examination of the
whole colon (total colonoscopy) (1). The same rules are employed for colonoscopy and
sigmoidoscopy. The expert performing the examination-gastroenterologist, physician,
surgeon-must have sufficiently long training and equipment including the necessary
accesoria and the patient must be prepared in the same way. The duration of the
preparation does not require more than 24 hours provided that the patient fulfils strictly
the instructions (ingestion of ethylenglykol), so the reamining problem is only the
duration of the examination in sigmoidoscopy and colonoscopy. Provided sufficient and
higher annual frequency of examinations the duration of colonoscopy should not be longer
than 30 minutes. Total colonoscopy should be performed particularly in family members of
the cancer family syndrom, where the tumour is very often localized in the right colon.
Radiological examination is advisable only in situation where attemps to perform total
colonoscopy were not successful. Larger studies showed that in positive FOB-test a finding
of benign tumours might be suggested in 6% and malignant ones in 2-3%. These tumours are
mostly at a resectable stage.
Preventive examinations should be different according to the history of the patient. The
first group should concern all citizens over 45 years, who are without any symptoms and do
not be - long to a risk group. The examination with FOB-test is performed annualy and in
positive cases colonoscopy is performed. The FOB-test is performed by the physician of the
first contact and colonoscopy at the gastroenterological center. All detected polyps
larger than 0,5 cm are removed endoscopically. A part of cancers of an early stage may
also be treated endoscopically. Others are treated surgically. The result must be
transmitted to the physician the first contact.
The second group is represented by patients with familial polyposis, previously proved
ademous polyps, patients after surgery for CRC, patients longstanding IBD and patients
coming from so called cancer families. In the patients preventive colonoscopy should be
performed in certain intervals. These intervals are longer in patients with negative
colonoscopic findings of following colonoscopies. FOB-testing, however, is necessary in
these patients annually. The interval will be individually different, for instance
according to biological quality of the polyp or to the extent and activity of the
inflammatory bowel disease.
The drive of our activity and approach of our health insurance must be the fact that
preventive program can lower CRC mortality. Studies on primary prevention of CRC
should continue, but secondary prevention could result in improvement of curves CRC
incidence and mortality in relatively short time. Success of our aim in highly influenced
by good information of potential candidates for CRC.
Jan Kotrlík, MD
ESGE Councillor
Department of Gastroenterology
IV. Med. Clin. 1st Med. Faculty Charles University, Czech Republic
Miroslav Zavoral, MD
Int. Dept. Fac. Policlinic Charles University,
Czech Republic
References
Introduction
Virtual endoscopy is a new procedure that has been made possible by the development of the helical CT scanner and powerful computers. The new helical CT scanners can obtain volume images quickly in a single breath hold providing high resolution images of luminal structures. Powerful computers can then take the data and display it as a single slice or as a sequence of slices formatted to look like an endoscopy. Thus, it represents a method of viewing the luminal surface of the bowel or respiratory tree and can simulate viewing from the perspective of an endoscopist. It has the potential for being a non-invasive method of screening for mucosally based mass lesions. This technology is in its infancy but promises to make a significant impact on the practice of gastrointestinal endoscopy. At this time, virtual colonoscopy and bronchoscopy have been the only procedures to be evaluated. Virtual bronchoscopy is technically easier because it requires no preparation, the lumen remains patent and motion artifact is minimal. It is conceivable, however, that other "virtual" procedures could be developed such as EGD, choledochoscopy and pancreatoscopy. This paper will just review virtual colonoscopy.
Technique
Preparation: The current technique of virtual colonoscopy
requires a full colon preparation. It is imperative that the colon be clean and dry to
minimize false positive examinations where stool is confused with a polyp. Glucagon is
used to paralyze the gut to minimize motion artifact. The colon is distended with air or
C02 to improve detection of small lesions and prevent areas of collapse from being
mistaken as cancerous stricture.
Helical CT Scan: The problem with conventional CT is that it cannot acquire a large
volume set with a single breath hold. Respiratory motion causes gaps to occur between
sequential images. The advantage for spiral CT is that while the patient holds their
breath, the table is moved through a rotating x-ray beam and whole volume data sets can be
obtained. Small lesions can be detected since respiratory motion is eliminated. To
optimize resolution, scanning parameters are set for a thin beam (3-5 mm), the smallest
pitch (1:1-2:1) and a narrow reconstruction interval (1 mm). The special resolution for
this technique is approximately 5 mm suggesting that polyps = 10mm should be routinely
detectable.
3-D Rendering: Once acquired, the digitized data set is transferred to a powerful
computer. 2-D (multi planar) and 3-D images can then be made. A technique called
perspective projection (objects closer to a users viewpoint appear larger than objects of
similar size that are farther from that viewpoint) is then applied to create 3-D images
and when displayed sequentially in real-time (15-30 frames/second) a "fly
through" is created. This is essentially a video examination of the colon surface
which simulates an endoscopy. Two rendering algorithms are employed: 1) surface rendering
- this provides a surface view of the colonic mucosa as if the colon wall was opaque; 2)
volume rendering - this provides a surface view of the colon as if the colon was
transparent. Volume rendering allows the operator to see "beyond" the colon to
adjacent structures. This method of reformatting the CT information is more time consuming
and takes more computing power.
Results
To date, there have been few published reports on this technique. David
Vining, a radiologist at Bowman Gray School of Medicine (Winston Salem, NC) was the first
to describe this technique (1, 2). The group from the Mayo Clinic has been the only group
to fully publish their data. Hara et al. published an unblinded study of patients whose
selection was selected based on having a positive barium enema. The sensitivity for polyps
greater than 1 cm, 5-9 mm and less than 5 mm was 100%, 71% and 11-28% respectively (3).
However, the importance of blinding became evident when this same group looked at their
sensitivity for polyps = 10 mm when participants were blinded. In this study, the
sensitivity for polyps greater than 10 mm was only 67% and the sensitivity for polyps less
than 10 mm was less than 30% (4).
In a study looking at the application of virtual colonoscopy in a screening population
(asymptomatic persons with no history of previous neoplasia), Rex et al reported on a
study where the CT data sets were acquired at one institution (Indiana University) and
then forwarded to Dr. Vining at Bowman Gray where their virtual endoscopy software
(FreeFlight) was applied using a Silicone Graphics Onyx Workstation (Silicone Graphics,
Mountainview, CA). Twenty-seven of fifty asymptomatic patients were fully evaluated.
Virtual colonoscopy detected three of nine adenomas greater than equal to 1 cm
(sensitivity = 33%), 3/8 adenomas 6-9 mm in diameter (sensitivity = 38%) and 3/34 were
adenomas = 5 mm (sensitivity = 9%) (5).
We have an ongoing trial at MUSC endeavoring to compare colonoscopy to virtual colonoscopy
in a population of patients who are either asymptomatic (have positive stool) or being
examined for surveillance purposes. Interim results show a 100% sensitivity for polyps or
masses greater than 20 mm (4/4), an 86% sensitivity for lesions 10-20 mm (6/7) and a 38%
sensitivity for lesions 5-9 mm (5/13) (Clive Kay-personal communication). Our trial
utilizes a Picker helical CT scanner with proprietary software developed by Picker (Picker
International, Cleveland, OH).
Based on the data to date, it appears that virtual colonoscopy as it is currently
performed has potential for detecting polyps over 1 cm in size. It’s current
sensitivity for polyps less than 1 cm appears to be poor.
The Future
Future developments in this exciting new technique will involve two fronts:
Technical Developments
Clinical Trials
In parallel to the technologic advances, these will need to be appropriately tested. Proper trial designs will be important in future studies looking at the sensitivity of virtual colonoscopy. Studies should involve blinding the interpreter to other test results, especially colonoscopy or barium enema. Inadequate blinding can dramatically affect sensitivity and the trials should include controls to insure a significant number of negative examinations. Patients should be stratified into a disease spectrum from symptomatic patients through surveillance and finally to include screening populations. It will also be important to have adequate sample sizes so that narrow confidence intervals can be obtained. Finally, colonoscopy should be included in the trial since this is the gold standard for sensitivity of polyps.
Summary
It is clear that virtual endoscopy is an exciting new technique which will likely have a tremendous impact on the practice of gastrointestinal endoscopy. It is equally clear that this technique is not yet ready for general clinical application. Hopefully with future developments, the idea of performing a brief (45 second) CT scan after a few days of ingesting a contrast material and with this data producing an "endoscopic view" of the colon which can accurately detect polyps = 5 mm in diameter is extremely appealing. It is conceivable that this could be achieved in the next 5 years. Additionally, there is no reason that this same approach could not be applied to the upper gastrointestinal tract and the pancreaticobiliary system. The reality of virtual endoscopy makes possible the futuristic concept that when a patient enters the hospital for treatment, he/she would undergo a total body CT scan. This creates a "data bank" of information available on this patient. In the course of further evaluation, if a bronchoscopy is needed, the data is simply reformatted into a virtual bronchoscopy. The patient is then found to have a heme positive stool, the data is reformatted into a virtual colonoscopy. The sinuses, the bile ducts and other "tubes" or spaces within the body could then be accessible for inspection by this method. This scenario may seem quite "far out" but may indeed become a reality; virtually, of course.
Robert H. Hawes, MD
Professor of Medicine Chief of Endoscopy, Medical University of South Carolina
Charlestown, USA
References
Clinical Outcames Research Initiatives (CORI)
In the current era of health care, physicians are increasingly being
asked to demonstrate that what they do in practice is effective, and enhances patient
outcomes. Endoscopy is commonly performed to evaluate gastrointestinal diseases. Decisions
to perform endoscopic procedures are complex. There are published guidelines which
summarize clinical situations when endoscopy may or may not be indicated. Although there
are some evidence-based reports, most guidelines are based largely on the consensus of
experts. In most cases the guidelines have not been evaluated in the clinical practice
settings where they are applied.
The American Society for Gastrointestinal Endoscopy (ASGE) identified outcome research in
endoscopy as a high priority during strategic planning sessions, and embarked on methods
to promote and encourage such research during the early 1990’s. The Clinical Outcomes
Research Initiative (CORI) is a direct product of this effort. The CORI project was
designed to pool endoscopic data from physicians in diverse practice settings to examine
why procedure are being performed, what is found, and ultimately to determine the impact
of procedure are key patient outcomes. The goal was to create a database that would be a
resource to the gastroenterology community by establishing a physician network to capture
endoscopy data using a computer-generated endoscopy report form. Endoscopy is well suited
for this approach because each procedure generates a report, and the reports can be
structured so that every entry represents an entry into the database. The report generator
produces a hard-copy endoscopy report and established a data file which can be exported to
the central data bank for analysis.
The implementation of the project began in early 1997 after 12 months of field-testing of
the database. The challenges of database development included creation of a user interface
that was intuitive, could be customized to meet individual clinician needs, included key
endoscopy data and could be completed in time required for dictation. Currently, nearly 60
physicians at 23 sites in the United States are using the database. Expansion to new sites
will occur during the next year, with sites outside the United States to be included.
The initial research goals are straightforward. The pooling of endoscopy reports provides
a "snapshot" of clinical practice in the United States. For example, the
database readily provides information about the indications for procedures, and can
provide a basis for evaluating practice variation in different geographic regions, and
different practice types (fee for service vs. health maintenance organization, etc). The
snapshot permits the linkage of indications and findings. For example, if patients are
undergoing upper endoscopy to evaluate reflux symptoms, how often is esophageal pathology
detected? Are there significant differences between the rates of neoplasia in the colon
based on indication for colonoscopy? Endoscopic findings can be linked to management
decisions.
The database can also be used for quality assurance activities. Data including how often
the cecum is visualized at colonoscopy, or rate of cannulating the desired duct at ERCP
can be determined. Complications – both major and minor – can be assessed.
The database can be used to assess trends over time. Changes in guidelines, medications,
endoscopic therapies can all be determined at different times. The impact of a new
guideline can be measured, both to determine how the guideline is being used and whether
desired goals are being achieved. Outcomes from therapeutic procedures can be determined.
Ultimately, patient outcomes such as quality of life and health care utilization can be
assessed if patients are tracked over time. Finally, the database will be useful to
identify patients with specific findings (such as Barrett’s esophagus) or diseases
(such ad inflammatory bowel disease) for clinical studies.
The snapshot provided by pooling endoscopic reports will be valuable, but should lead to
hypothesis development for clinical studies. Such clinical studies may require more
precision or data than is normally provided in a routine endoscopy report. In such cases,
sub-menus can be easily added to the core database to acquire additional data.
The ASGE has long encouraged thoughtful evaluation of endoscopic procedures and produced
important clinical guidelines for endoscopy. The Society has always promoted the safe and
effective use of endoscopy. The CORI project represents another step toward critical
examination of the role of endoscopy in clinical practice settings. The database will be a
valuable resource for the larger GI community as it provides benchmarks of what we are
currently doing, and encourages the development of endoscopic outcome studies.
David Lieberman, MD
Professor of Medicine Oregon Health Sciences University
Chief Gastroenterology Portland VA Medical Center
Portland, USA
Report on the Ljubljana ESGE-Endoscopic Workshop on Advanced Endoscopy
On July 4 to 5, 1997, Workshop on Advanced Endoscopy was held in
Ljubljana, capital of the Republic of Slovenia. Each year, presentation of the latest
endoscopic techniques and the newest endoscopic instruments is arranged by the European
Society of Gastro-Intestinal Endoscopy (ESGE) in one of the countries of the eastern and
central Europe. Endoscopies are performed by the leading experts in gastroenterologic
endoscopy assisted by specialists of the hosting country.
This year, Medical Department of Gastroenterology, Ljubljana, was appointed to host the
Workshop. The programme was carried out by the following foreign specialists, assited by
Slovene endoscopists: Friedrich Hagenmüller - Hamburg, Joseph R.Armengol-Mirò -
Barcelona, Aksel Kruse - Denmark, Alberto Montori - Rome, Andrzej Nowak - Katowice, Janos
Papp - Budapest and Thomas Rosch - Munich.
The entire programme of the Workshop was broadcast so that the participants were able to
follow the procedures on a screen erected in the Medical Faculty lecture room. The team of
the Ljubljana Congress Centre should be complimented for the outstanding quality of the
programme broadcasting.
The programme of the first day covered the following procedures: simple
gastroduodenoscopy, emergency gastroscopy and endoscopic resection of a giant gastric
polyp. Bleeding from the stomach following the resection was successfully controled by
sclerotherapy. Other procedures included percutaneous endoscopic gastrostoma (PEG)
creation, endoscopic retrograde cholangiopancreatographies and endoscopic
sphincterotomies, followed by insertion of endoprostheses, removal of stones by means of
various baskets, presentation of baloon catheters and brushes for collecting cytology
specimens. Endoscopic examination of the common bile duct was certainly the most
interesting procedure in the series. After sphincterectomy, two endoscopists inserted the
endoscope deep into the bile ducts, defined the presence of a tumour, and obtained
brushings for cytologic studies. The participants were also shown endoscopic
ultrasonography of the oesophagus, stomach, bile ducts and pancreas.
The programme of the second day featured placement of an endoprosthesis through a part of
the oesophagus narrowed by malignant growth. Two colonoscopies involving removal of
polyps, and several sphincterectomies with insertion of endoprostheses concluded the
Workshop programme. Throughout the Workshop the endoscopists answered questions and
explained the procedures.
Seventeen diagnostic and therapeutic endoscopic procedures were carried out during the
Workshop. The meeting brough together 150 participants from 14 countries of the eastern
and central Europe. The participants complimented the organizers for their work,
especially for judicious selection of cases for presentation. Professor Hagenmüller, the
ESGE President , who closed the Workshop said that the participating endoscopists enjoyed
working with the Ljubljana endoscopic team and complimented them for having organized the
Workshop in cornpliance with the ESGE prepositions and for their strict adherence to the
ESGE standards on cleaning and disinfection of endoscopic instruments. All the guests
praised the work done by the doctors and nursing staff of the endoscopic unit of the
Medical Department of Gastroenterology, Ljubljana, and stressed the role of the
participating radiologists and radiologic technicians.
Prof. I. Krizman
President Local Organizing Committee
Esophageal Cancer Workshop Witnessed Historical Moment in Hong Kong
A one-day workshop on esophageal cancer, hosted by the Chinese
University of Hong Kong and the Hong Kong Society of Digestive Endoscopy, was held in the
midst of an historic occasion in Hong Kong, namely the hand-over of the British colony
back to her mother land, China. Over one hundred overseas delegates representing societies
of Gastroenterology and Digestive Endoscopy were invited to participate in the symposium
and witness the change of sovereignty in Hong Kong.
Professor M Crespi presented his epidemiological studies in Iran and China, pointing out
that dietary habit and smoking are important risk factors in the development of esophageal
cancer. Professor Lok Tio presented their on-going mass screening program for esophageal
cancer in China using cytology and dye spray technique in esophagoscopy. Dr. Kida compared
the pros and cons of CT, MRI and EUS in the diagnosis of esophageal cancer and emphasized
that these modalities are complementary to each other. Dr. Inoue presented and
demonstrated his technique of endoscopic mucosal resection of early esophageal cancer.
Surgical treatment of esophageal cancer and endoscopic palliation was reviewed by
Professor Endo and Dr. Angus Chan. The climax of the meeting was an one-hour live telecast
demonstration of esophageal stenting performed by Professor Sydney Chung in Hong Kong
followed by a talk on chemo-radiotherapy given by Professor T Hennessy and live
demonstration from Glasgow by Dr. Robert Stuart’s team. This part of the program was
transmitted to Glasgow by ISDN tecnique as part of a telemedicine program at the Chinese
University of Hong Kong.
The workshop was concluded by a dinner party in which the audience participated in the
Sino-British hand-over ceremony via live transmission from the Hong Kong Convention and
Exhibition Center. The audience were amazed by the splendid fire work displayed in
Victoria Habour celebrating the beginning of a new era in Hong Kong.
Joseph Y. Sung MD
Professor, Chief of Gastroenterology Hepatology Chinese University of Hong Kong
The length of the small intestine makes visualization of its mucosa by endoscopy a challenging undertaking. A wide variety of endoscopic maneuvers have been utilized to overcome these challenges. These include per os colonoscopy, which may reach up to 50 cm beyond the ligament of treitz and most recently the development of specifically designed small bowel endoscopes, including both push and sonde types.
Push Enteroscopy
Push enteroscopes usually have a working length of 279 cm. An overtube
is backloaded onto the enteroscope which when advanced into the duodenum and prevents
looping along the greater curvature in the stomach. This allows examination of the small
intestine up to 150 cm beyond the ligament of treitz. This technique allows excellent
mucosal visualization and offers therapeutic capabilities so that therapy or biopsy of a
lesion is possible at the time of detection.
Overall the small intestine is the source of gastrointestinal bleeding in less than 5% of
patients. However we and others have found that in patients with occult gastrointestinal
bleeding greater than 50% of bleeding sites occur within range of push enteroscopy. Chong,
Barkin et al reported the use of push fiberoptic enteroscopy in 55 patients with occult
gastrointestinal bleeding. They made a diagnosis in 35 (64%) patients, and 21 of the 35
patients (60%) had lesions that were located proximal to the ligament of Treitz. The yield
when investigating patients with suspected small intestine disease by taking small
intestine biopsies through the enteroscope varies from 42 to 86%.
The technique is safe. The infrequent reported complications are related to placement of
the overtube, and include Mallory Weiss and esophageal tears, mucosal stripping and
pancreatitis related to trauma of the papilla of Vater. Thorough examination of the upper
gastrointestinal tract prior to placement of the overtube, and careful insertion aided by
fluoroscopic guidance may limit these complications.
Sonde Enteroscopy
The most distal portion of the small intestine is not visualized when using push enteroscopy, while the sonde enteroscope makes visualization of the distal small bowel more accessible. Sonde enteroscopy involves placement of the long sonde scope through the nose which is then carried by peristalsis through the small bowel. While sonde enteroscopy permits more distal examination of the small intestine it does not visualize the entire lumen, is time consuming to both the patient and the physician and has no therapeutic capabilities. Lesions are found in the small intestine in 11 to 49% of patients with occult gastrointestinal bleeding or anemia. Complications of the procedure include epistaxis in 5 to 14% of cases; diarrhea may occur due to the administration of prokinetic agents which are given to induce distal penetration of the sonde scope and small intestine perforation in 3% of cases. The technical complications are largely related to failure of passage of the enteroscope through the nose or through the bowel.
Intraoperative Enteroscopy
In the investigation of occult bleeding intraoperative enteroscopy (IOE)
has demonstrated lesions in the small intestine in 11 - 100% of cases. We utilize this
modality in patients with occult gastrointestinal bleeding who continue to have ongoing
bleeding and a clear source is not otherwise found. IOE permits evaluation of the entire
length of small intestine, both the mucosal and serosal surfaces as well as offering
therapeutic capabilities. IOE can be useful to evaluate small intestine etiology of acute
gastrointestinal bleeding and structural lesions such as Crohn’s disease, radiation
enteritis and small bowel neoplasia. Small intestine lesions are detected in suspected
intestinal Crohn’s disease in 47 to 61% of cases. The yield when investigating
patients with Peutz Jeghers syndrome was reported at 100%, and all patients successfully
underwent endoscopic polypectomy.
The procedure involves either the passage of the enteroscope per os or via a surgical
enterotomy and then manual advancement of the enteroscope by the surgeon. Clinical
complications of IOE range from 16 to 56% and include meseneteric hematomas or tears and
pancreatitis. These may be attributed to the surgical aspect of the procedure. The sole
reported technical complication of IOE relates to the failure of passage of the instrument
due to dense adhesions of the mesentery.
Conclusion
All patients who present with recurrent clinically significant bleeding should undergo careful upper endoscopy and colonoscopy. If these are both negative the patient should undergo push enteroscopy. This remains an important step because if diffuse angyiodysplasia is found these patients are not operative candidates. If isolated angyiodysplastic lesions are found these can be treated when using the push enteroscopy, and the patients observed. If bleeding persists despite therapy or if the initial examination is negative, patients may be healed pharmacologically or should undergo intraoperative enteroscopy for definitive management.
Jamie S. Barkin, MD, FACP, MACG
Lyle K. Hurwitz, MD
School of Medicine/Mt. Sinai Medical Center
Division of Gastroenterology
University of Miami, Florida
References
Functional Dyspepsia-What is it? What should we be doing about it
The term "functional" has been applied to those gastrointestinal disorders which do not demonstrate a basic biochemical, hormonal, molecular or pathological abnormality, yet, which give rise to acute or chronic gastrointestinal symptoms (1). They are assumed, though often not proven, to represent an abnormality of gastrointestinal "function", thus the apparent appropriateness of this term. Included in this broad spectrum of disorders are some patients with gastroesophageal reflux (i.e., those without esophagitis or complications of Gerd), patients with pain of esophageal origin, non-ulcer dyspepsia, in its many manifestations, and the irritable bowel syndrome and patients with otherwise unexplained constipation and diarrhea. With the helicobactor revolution and an apparent decline in peptic ulcer prevalente in che Western world, dyspepsia, however it is defined, has now emerged as a major challange for the clinician, investigator and endoscopist.
Dyspepsia - Definition
Dyspepsia is an unfortunate term, I believe. Though we all have a mental
picture of the dyspeptic patient, our problems begin when we attempt to define this
condition in real terms. A further problem with this term is that within this concept of
dyspepsia are included a tremendously wide range of clinical scenarios, which extend from
the patient who has occasional post-prandial fullness to those unfortunate individuals who
are unable tolerate any oral intake because of nausea and vomiting, and are dependant on
total parenteral nutrition.
In the past several years, considerable effort has been expended on devising a clinical
definition of dyspepsia that is meaningful and reproducible (2-4). Of the constellation of
symptoms that have been examined, several have been found to be poorly specific and
reproducible. Thus, such symptoms as post-prandial fullness and bloating have proved to be
non-specific, and most attention has focused on abdominal pain (5-8). Talley and
colleagues have suggested that dyspepsia be narrowly defined as a "persistent or
recurring pain or discomfort centered in the upper abdomen" (4). Many definitions
have emphasized the importance of the post-prandial nature of these symptoms. Another
problem with dyspepsia is that it is evident that there is considerable overlap between
patients with non-ulcer dyspepsia and other functional disorders (9-10). Some patients
have significant gastroesophageal reflux, while others may well be a part of the spectrum
of the irritable bowel syndrome (IBS). In an attempt to provide a classification of
dyspepsia which would be helpful in directing therapy, dyspepsia has been subclassified on
the basis of predominant symptoms into three subgroups – reflux-like dyspepsia,
ulcer-like dyspepsia and dysmotility-like dyspepsia. Unfortunately, further investigations
have revealed that these subgroups have little basis in terms of pathophysiology, and
their definition does not accurately predict reponse to a particular modality of treatment
(9-10). In an important recent study, Stanghellini and colleagues have suggested that,
while the presence or absence of any particular symptom is not predictive of the presence
of underlying gastroparesis, the severity of certain symptoms may help to identify those
patients who have an underlying gastric motor disorder (11).
Dyspepsia illustrates, therefore, the dilemma we face with all these functional disorders.
They are defined, not on the basis of an underlying biochemical or pathological
abonormality, but, rather on the basis of certain symptoms or symptoms clusters. It must
also be remembered that symptoms are, indeed, highly subjective – recent studies in
constipation, for example, have emphasized the tremendous variation in a patient’s
understanding of such an apparently straightforward symptom (12). It seems likely that we
will eventually discover that dyspepsia includes, within is broad umbrella, a wide
spectrum of primary pathologies which may range from loss or damage to enteric neurons to
psychopathology. The inadequacy of our definitions and the likelihood that this disorder
does not represent a single homogenous entity may go a long way toward explaining the
inconsistency of various investigations among dyspeptic patients (13). Several factors
will similarily influence the yield of any diagnostic intervention, including endoscopy,
in dyspepsia.
What is the Role of Endoscopy and Dyspepsia?
A number of diagnostic options are available to the clinician confronted
with a dyspeptic patient. He or she could make a diagnosis based on symptoms alone, could
proceed to endoscopy or an upper gastrointestinal barium study or could treat empirically
and base diagnosis on the response to therapy. Based on the most popular hypotheses for
the etiology of dyspepsia, the main classes of influenced by whether the patient is seen
in a primary care physician’s office, a specialist referral center, or the hospital
intensive care unit.
The second question we need to address is what influence endoscopic findings have in
management, in other words, what findings really matter? In the area of gastroesophageal
reflux disease, endoscopy may prove diagnostic, can assist in predicting prognosis and, in
particular, the likelihood of response to various classes of therapeutic agents and, most
impontantly, will detect Barrett’s esophagus. For peptic ulcer disease, endoscopy
will again prove diagnostic, will confirm complications and, of course, can provide a
diagnosis of Helicobacter pylori. Finally, and perhaps of greatest concern to the
practicing clinician, endoscopy is the most accurate available tool for the diagnosis of
gastric cancer. Indeed, one of the most popular arguments for widespread use of endoscopy
in dyspeptic patients has been to detect gastric cancer and early, potentially curable
gastric cancer, in particular. Several unresolved questions complicate our understanding
of each fo these areas. Thus, the true prevalence of Barrett’s esophagus remains
unknown, and the significance, in particular, of so-called "short-segment
Barrett’s" is unclear. The need to carefully evaluate and biopsy gastric ulcer
is based on the concept of the "ulcer cancer". While it is clear that early
gastric cancer can masquerade as otherwise apparently typical peptic ulcers, the true
prevalence of ulcer cancers is also unclear. Finally, with relation to gastric cancer
itself, the influence of widespread endoscopy on the overall natural history of gastric
cancer is far from clear. Endoscopy also has therapeutic potential and it is possible, at
the same sitting, to dilate strictures, arrest hemorrhage and, of course, obtain tissue
for specific pathological diagnoses.
Where are we, therefore, in 1997 with endoscopy in dyspepsia? National governments,
insurance companies, and healt care providers have voiced considerable concern regarding
the costs of endoscopy and, in the United States at least, have introduced algorithms for
the evaluation of dyspepsia which often place endoscopy at some remove from the patient.
Advocates of endoscopy have, unfortunately, a paucity of data available tothem to support
its widespread application. Indeed, in a recent careful analysis, Axon suggested it is
difficult to justify endoscopy in the younger patient with dyspeptic symptoms, given the
age distribution of gastric cancer in the United Kingdom (17). In the decision making
process, therefore, the clinician should base a decision on whether or not to proceed to
endoscopy on, firstly, the likelihood of finding a significant disease process in an
individual patient. This, as mentioned above, is highly dependent on the patient’s
age, their geographic location, and the clinical setting in which they are being assessed.
Choosing endoscopy or, indeed, any other diagnostic test, must also take into account
their relative accuracy. Thirdly, a clinician must include some assessment of the relative
influence of these various tests on patient outcome. This, in turn, will be based on
assumptions of efficacy for therapeutic alternatives, be it Helicobactor pylory
eradication, acid suppression, prokinetic therapy or even surgery.
For the moment, finally, costs has become a major issue. Several analyses have attempted
to provide a cost-benefit ratio for a variety of diagnostic pathways in the dyspeptic
patient (18). Their varying results are related to differences between these models in
certain assumptions such as the prevalence of Helicobactor pylory, the efficacy of HP
therapy and the likelihood of success or failure of empiric therapy. It is clear,
therefore, that at this point in time, prospective studies, in real patients, in the
"real world" which truly evaluate the efficacy of endoscopy in the assessment of
the dyspeptic patient have not been performed. In the meantime, the clinician must
individualize his/her decision based on available information, that is, of course, while
they still are in a position to make these decisions!
Eamonn M.M. Quigley, MD, FRCP, FACG
Chairman, OMED Research Committee
University of Nebraska, U.S.A.
References
Diagnostic and Operative GI Endoscopy: Quality Assurance and Education in Middle-Eastern Europe
Diagnostic and therapeutic endoscopy has become an essential procedure in clinical gastroenterology. The constantly growing amount of technological and biomedical knowledges, the permanent research for and through endoscopes (Tab. I) were introduced into our everyday clinical life. The definition of standards in endoscopy is an identical part of the quality assurance in gastroenterological work.
Needs of standards in gastrointestinal endoscopy
Ultimate goal in healthcare should be to increase the likelihood of
desired health outcome consistent with current professional knowledge. Elaboration of
generally valid and dynamically updated standards, introducing of audits for internal
control and continuous improvement are the most important and useful tools to achieve
these purpose.
The well-defined and in 1991 by the European Community accepted principles of Good Clinical
Practice (GCP) may give essential help to the realization of these aims. With
respect to quality assurance, health care may be divided into elements of structure,
process and outcome. The realization of these principal approaches is depending upon
several practical requirements, the basic elements of these processes are demonstrated on Table
II.
To illustrate some of the above topics in detail, I try very shortly to summarize the
contents of certain proposed standards:
Practical possibilities in approaching quality assurance in
gastrointestinal endoscopy are shown on Figure 1.
One of the most important tool is for this task the data processing, which can be used to
assess and analyze all of the elements demonstrated on the figure. To approach the
internal quality control – we have two different possibilities (Fig.2).
In the first case, quantitative analysis is compared to data from different units or the
literature. This is certainly important and useful. Experience in the industry, however
has shown that quality control by continuos improvement may be even more successful and
more acceptable. In this case, analysis of the data of a single unit is used as a basis to
improve standards only in this unit without comparison to other centers, e.g. the
complication rate is not analyzed with respect to complications in other units but with
respect to own unit, forcing the analysis of the cause of complications, discussions of
how to improve the procedure and so forth.
Standards and quality assurance in gastrointestinal endoscopy has become a matter of
increasing interest, and produced a valuable development in Western countries from
medicolegal and ethical standpoint as well as from economical aspects. In the Middle and
Eastern European countries three essential steps are needed to reach similar results:
Training and education in Hungary: efforts and results
The past 40 years of medicine in the so-called socialists countries have been characterized by extreme effort on the part of doctors working in clinical medicine to provide the highest possible quality of care for their patients confounded by an inadequate distribution of financial resources, ideological and bureaucratic distortion of social insurance, medical education and hospital organization, and a disastrous personal counterselection among family doctors. These doctors must return now to the classrooms to refine and improve their medical knowledge and communication skills. However, there are several special aspects of training and education in GI endoscopy, which can be hardly reached in the Eastern European countries, due to the before mentioned reasons. Based on the Omge Education Working Party guidelines, I show you these special problems very shortly, practically in catch-words:
Recognizing these requirements, and considering the improving conditions
in Hungary, we tried to start on two ways.
First, the organization of education till now in Hungary has to be essentially
restructured (Fig. 3).
Moreover, together with our Middle-European Colleagues, we should coordinate our
educational activities, and help the other countries, in particularely the former Soviet
Union States to enter into the scientific circulation of European Community. The EC
sponsored 1st Esge Integrated Post-graduate Course "Theory and Practice in the
Education of Gastroenterology"in 95, Hungary ment the first step of the
information-technology rapprochement and didactical-theorethical transformation in
educational way of thinking. Experience and problems arisen during this exciting meeting
are listed in the following:
Special aspects of training and education in gas-trointestinal endoscopy with respects to the conditions in Middle-Eastern Europe
Finally, after having demonstrated these quite pessimistic data and situations, I should like to outline my personal optimistic feelings. Working in these developing countries, we have to learn a lot from the good and worse experiences of the western societies, and I hope that we will be lucky enough, to keep away our renewed education system from their initial wrong ways. I am really convinced, and we already tried to start in Hungary, that Peter Cotton’s standpoint and principles are correct: we need multidisciplinary teams in a "Digestive Disease Center", in wich the only real criteria for specialist activity are correct training and motivation.
L.A. Simon, MD, PhD
Dept. of Gastroenterology, Tolna Conty Teaching Hospital
Szekszárd, Hungary
References
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