World News in Digestive Endoscopy
Issue 9, September 1998

The outgoing

Four years of intense and passionating work, first as Secretary General and, in the last 18 months, also as President due to the sad loss of Professor Rodolfo Cheli, teached me a lot. One major lesson is that still it is possible to find persons, colleagues, full of enthusiasm and keen to invest in non profit activities part of their overloaded professional time: I have to thank very warmly these colleagues, because without their help and advice it would have been difficult to fulfill the many tasks accomplished during these four years.

A second point I wish to stress is the growing self-consciousness in several countries of the key role of endoscopy in medical practice and the emerging need to keep together those practicing "the tube" because of common problems in defining their identity and in adding dignity to their work. The Societies and/or Groups devoted to endoscopy did increase during these years and it becomes more and more important to help them with a regular dissemination of news. In this respect the OMED Newsletter and Website seem to be the winning option.

A lot more of work remains ahead of us. I am confident that the new OMED management and the planned enlargement of the scopes and functions of the Committees will be able to respond positively to these tasks. To the new President and Board my best and sincere wishes for a fruitful activity.

The incoming

It is an honor and a great challenge for me to become President of the World Society for Digestive Endoscopy (OMED). No doubt, it is an honor to represent, Digestive Endoscopy and the endoscopists at a worldwide level. However, it represents also a great deal of hard work to face the numerous challenges that will appear during my term as President.

In the past, when rigid endoscopes were used, there were only few endoscopy societies around the world. With the advent of fiber-optic instruments, gastrointestinal endoscopy became a very attractive specialty, because of its increasing role in clinical diagnosis and management. Consequently a considerable number of endoscopy societies were founded. It was agreed that these societies should be put together according to their geographic location. Therefore three zones were credited, respectively the Asian-Pacific zone, the European zone and the Inter-American zone. Next step should be to congregate them towards a central coordination. It took until the 70’s for the foundation of OMIED as the organization with the responsibility to oversee endoscopy, throughout the world. During this early stage, OMED was an amadoristic society, with no financial support and, therefore, with very few plans. Of course, it became necessary to have World Congresses of the specially. It was decided to have them in association with the already established World Congresses of Gastroenterology (WCOG). In this embryonic status, OMED was a "token" representative to the planning committee of the World Congresses. It was in the WCOG hold in Sao Paulo in 1986, then in Sydney in 1990 and finally, in Los Angeles in 1994 that it was given to OMED representatives the real possibilities to play a role in the organization of such congresses. A small portion of the registration fees and some extra-money from OMGE were given to OMED, though not sufficient to fulfill its aims.

Presently, OMED is experiencing a deep transformation. Thanks to the efforts of Massimo Crespi, Alberto Montori and Rodolfo Cheli has now established plans, such as educational programs for developing countries, videotape courses to be linked to either national congresses, meetings of’ endoscopy societies, hospitals or medical societies, and research projects.

For the next 4 years (1998-2002), during my term as President, my efforts will be focused in some priorities, such as:

1. To maintain OMED representing Digestive Endoscopy at a worldwide level by encourages and stimulating close cooperation and interchange between the Organization and it’s 3 Zones.

2. To maintain OMED as an independent organization. Since the introduction and the development of therapeutic, as well as the constant advances in technology, endoscopy has gained a unique position amongst Clinical Gastroenterology, Surgery (general and colorectal), Pathology and Radiology. Therefore, endoscopy must interact and be, regarded as, integral of clinical problems solving. Nowadays, it is not possible to treat Endoscopy as a secondary or adjunct to any specialty.

3. To encourage the adoption of OMED endoscopy training program as suggested at the Seminars on Education held at the Wordll Corngresses in Sao Paulo, Sydney and Los Angeles. Supervision of such programs will be responsibility of the education committees of each zone, according to their possibilities, under the coordination of OMED Education Committee. This would not interfere with the continuation of the educational program project for developing countries and with the videotape courses, already in course under Dr. Crespi.

4. To develop research activities, coordinated by OMED Research Committee.

5. To maintain and to stimulate standardization of Endoscopic Terminology under supervision of OMED Terminology Committee..

6. To maintain transmission of information by maintenance of the OMED Newsletter, the internet address and the web page.

7. To foster a close cooperation, with OMGE, scientifically, socially and economically.

OMED should have a permanent seat on the OMGE board with full voting privileges. On the other hand, OMGE should also have a permanent seat on the OMED board.

It is necessary OMED to be recognized as a full partner in the organization of the World Congresses of Gastroenterology and Endoscopy by OMGE.

It should be OMED’s responsibility to ensure a proper balance of endoscopic topics at those Congresses.

In addition, OMED should receive proper financial support from the profits of the WCOG in order to carry out its activities in administration, education, research, terminology and the other activities mentioned above.

This would include a need for committee meetings to be held at least twice a year (usualy during DDW and UEGW).

In summary, there is a great deal of work to be done. We need the support of endoscopists throughout the world to ensure that OMED is a reality.

Glaciomar Machado, MD
OMED, President 1998-2002

Glaciomar Machado Incoming President of OMED.
Introducer: Melvin Schapiro (President SIED)

Glaciomar Machado becomes the President of OMED during the VIII World Congress of Digestive Endoscopy in Vienna

It is with great pleasure and honor that I introduce you to our new President of OMED, Professor Glaciomar Machado. All of us who know and love him have come to simple call him Glaciomar as he is truly the representative of all of us.

Dr. Machado graduated in Medicine from the "Faculdade Nacional de Medicina da Universidade do Brasil" in 1966, and now, as Professor of Gastroenterology, has ascended to the position of Chief of the Gastroenterology section of that University in Rio de Janeiro.

Glaciomar’s background reflects a broad international training in Endoscopy and Gastroenterology. He served a fellowship under Dr. John Fordtran in the USA, studied Early Gastric Cancer Detection in Japan with the support of the Japanese government, completed a Ph.D. degree at the University of Bristol in England, and participated in academic programs throughout the world.

Glaciomar is one of the pioneers of modern diagnostic and therapeutic endoscopy. He was among the first to recognize the potential of, and utilize fiber optic endoscopes. He introduced ERCP to Latin America in 1973, EPT in 1975, and initiated the therapeutic endoscopic techniques of electrosurgical treatment of esophageal rings, and of choledocoduodenostomy.

Among his many contributions to the scientific literature, Glaciomar is the author of the only text book on Therapeutic Endoscopy in the Portuguese language. He is fluent in English, French, and Spanish and has participated as faculty of major Congresses throughout the world. He has been part of the scientific programs for the World Congresses in Mexico City, Madrid, Stockholm, Sao Paulo, Sydney and has delivered the "Schindler Lecture" at the WCOG in Los Angeles.

Glaciomar’s appointments and responsibilities have given him the extensive background necessary to serve our Society well as its next President. He is a member of the Brazilian Academy of Medicine where he holds the chair no. 18, has served as President of the Rio de Janeiro Digestive Endoscopy Society, President of the Brazilian Society for Digestive Endoscopy, President of the Inter American Society for Digestive Endoscopy and Secretary-General for the WCOG in Sao Paulo in 1986. In OMED Glaciomar has served as Secretary-General, vice President of the American Zone, and Chairman of the Education Committee.

I have been privileged to know Glaciomar as a kind, considerate, thoughtful and conscientious leader. Our Society will grow and prosper under his direction.

OMED Post-Graduate Course, Rome June 1-2, 1998

The Post-Graduate Course was organized within the 6th World Congress of Endoscopic Surgery under the auspices of the OMED, the EAES and the SAGES. The coordinators were J.R. Armengol Mirò, M.D. and M. Crespi, M.D. for OMED, Sir A. Cuschieri, M.D. and J.J. Jakimowicz, M.D. for EAES and J. Ponsky, M.D. and G. Van Stiegman, M.D. for SAGES

This interesting and successful Course was followed by 322 participants for 10 hours a day.

This Post-graduate Course with live interactive demonstrations (16 patients operated in 2 days) with Satellite connection with the Auditoruim of Alitalia where the Nurses’ Seminar took place and with the Hospitals in Milan and Taranto.

The Post-graduate Course was dedicated to "Diagnostic and Interventional Flexible Endoscopy; Interventional Radiology and Endoscopic Surgery: Competing, Complementary, Combined?". The contribution and participation of about 40 specialists in the different minimally invasive methods has brought up the possibility of managing patients through a cooperative efforts. When involved in the management of patients, only the knowledge of the possibilities and limits of each diagnostic and therapeutic approach makes it possible to achieve the best outcome with the lowest morbidity and costs. The Post-graduate Course has been focused mainly on all management options of digestive diseases of surgical interest, including interventional radiology and flexible endoscopy, with updating of all new-coming technologies, from the ultimate imaging technologies to the future role of telerobotics and virtual reality. The technological evolution has been indicated as the path for future wider and wider application of the principles of minimally invasive surgery.

Nonetheless, technology has not been the only commitment of the Course, where special regard has been given to the study and treatment of pre-cancerous lesions, early cancers and other malignancies. Therefore, at the end of the Course, the new profile for the Surgeons of the 3rd millennium has been drawn: an expert in sophisticated technology; good hand skills but also deep cultural roots.

Photodinamic Therapy for Esophageal Disease

Photodynamic therapy (PDT) involves the systemic use of a photosensitizing drug which is activated by a light of proper wavelength and power to produce cell death. Cancers have preferential concentration of the photosensitizers allowing the physician to somewhat selectively treat malignant tissue and to degree spare normal tissues. The primary use for PDT in gastroenterology has been in esophageal cancer but trials are now underway to evaluate treatment effect in Barrett’s esophagus with dysplasia and in other GI cancers including biliary and colonic.

Porfimer sodium (Photofrin®, QLT Photo Therapeuctis, Vancouver, B.C.) is the pothosensitizer most used in clinical trials. It is now approved for use in certain types of esophageal cancer in the United States, Canada, the Netherlands, Japan and France. Photofrin® is also undergoing clinical trials in head and neck cancer, brain tumors and Barrett’s esophagus. Second generation drugs currently being tested in esophageal disease include 5-aminolevulinic acid and mTHPC.

With Photofrin®-PDT, the drug is injected IV followed by endoscopy in 40-50 hours. A cylindrical 2.5 cm diffuser attached to a fiberoptic probe carries dyelaser red light (630 nm) to the targeted esophageal disease. The light is delivered over a specified time (usually 12.5 min). One or more esophageal segments can be tereated during each session. Improvements in diffusers and other methods to deliver the light to the tissue should dramatically reduce the treatment time. Light delivery with Photofrin® can be repeated in 48-72 hrs if needed to achieve additional tumor destruction. Patients are usually treated in the outpatient setting.

Tumor destruction with PDT is significant. As expected, chest pain and nausea commonly occur following treatment but resolve in several days. Fever to 100-101° can occur. Sympathetic pleural effusion are also common following therapy. Perforation is unlikely but esophageal strictures occur in 10-40%.

Depending on clinical needs, more than 1 PDT session can be administered.

However, if PDT is going to be effective, 1 treatment typically improves cancer induced dysphagia. The duration of PDT response varies but is typically longer than the palliative effect of YAG laser. Photofrin® remains in body tissues for approximately 1 month necessitating the patient to protect themself from direct sunlight exposure during that period.

Sibille et al reported on 123 patients treated with PDT for esophageal cancer.

PDT was used as a singular therapy in 56 patients and as part of a multimodal protocol in 67. They found no difference in the response rate between PDT and multimodal therapy. A complete response at 6 months was obtained in 87% (99 of 114). Local recurrence occurred in 36 of these 99 patients 12 to 18 months later. For patients with uT1 and uT2 lesions 5 year survival was 33-36%. Many of these patients were non-operative candidates.

Photofrin®-PDT for Barrett’s esophagus and dysplasia or early esophageal cancer has been used most extensively by Oberholt et al. Using an esophageal centering balloon, they have treated over 200 patients. In their first 100 patients, high grade dysplasia (HGD) was eliminated in 88%, low grade (LGD) in 92% and Ut1 cancers in 77%. When combined with thermal ablation of small residual islands of Barrett’s persisting after PDT, complete elimination of Barrett’s was accomplished in 43 patients. Strictures occurred in 34% of patients but all responded to dilation. Subsquamous glandular mucosa was found in only 2 of the 100 patients but 2 others developed small nodules of HGD which were successfully retreated. One additional patient developed a small subsquamous adenocarcinoma which was also successfully retreated. Photofrin®-PDT is now being studied in an international, multi-center clinical trial in patients with Barrett’s esophagus and high grade dysplasia (HGD).

Gossner et al have used 5-aminolevulinc acid (5-ALA) induced protoporphyrin IX PDT to treat 32 patients with severe dysplasia or uT1 cancers with elimination of dysplasia in all and of 17 of 22 cancers. Malignancies greater than 2 mm deep required mTHPC PDT for deeper tissue effect. Barr et al have reported on 5 patients treated with 5-ALA-PDT. In both studies, persistence of subsquamous Barrett’s occurred and re-epitheliation with squamous mucosa was only partial following PDT.

In conclusion, PDT appears to hold considerable promise as an endoscopic therapy for palliating GI cancers and for curative therapy of dysplastic mucosa or superficial GI tract malignancies.

REFERENCES

– Lightdale CJ, Heier SK, Marcon NE, McCaughan JS, Gerdes H, Overholt BF, Sivak MV Jr, Stiegmann GV, Nava NR. Photodynamic therapy with porfimer sodium versus thermal ablation therapy with Nd:YAG laser for palliation of esophageal cancer: a multicenter randomized trial. Gastrointest Endosc 1995; 42: 507-512.

– Overholt BF, Panjehpour M and Haydek J. Photodynamic therapy for Barrett’s esophagus: follow-up in 100 patients. Accepted for publication, Gastrointest Endosc, 1998.

– Gossner L, Stolte M, Sroka R, Rick K, May A, Haln EG and Ell C. Photodynamic ablation of high-grade dysplasia and early cancer in Barrett’s esophagus by means of 5-aminolevulinic acid. Gastroenterology 1998; 114: 448-455.

– Bar H, Shepherd NA, Robert DJH et al. Eradication of high grade dysplasia in columnar lined (Barrett’s) esophagus by photodynamic therapy with endogenously generated protoporphyrin IX. Lancet 1996; 348: 584-585.

Progress Towards a National Bowel Cancer Screening Program for Australia

Over the last 15-20 years, there have been a number of impressive achievements in cancer control in Australia. The most dramatic has been the substantial reduction in incidence and mortality of lung cancer in men as a result of media campaigns against tobacco use and legislation banning tobacco advertising. Incidence of lung cancer has now fallen below that of bowel, prostate and breast cancer. In addition, programs aimed at primary prevention or early detection are in place for control of cervical cancer, breast cancer, melanoma and non-melanotic skin cancer. However, until recently, bowel cancer has been neglected, despite the fact that it is the commonest cancer affecting both men and women in Australia and the second commonest cause of death from cancer after lung cancer .

The major reason for neglect was the lack of consensus among medical experts about appropriateness of screening for bowel cancer. Screening was "controversial". Without an agreed message, State Cancer Societies concentrated on symptomatic bowel cancer but gave the general topic of bowel cancer a low profile in their educational programs.

All that has changed. In 1991, the Australian Gastroenterology Institute (AGI), the educational arm of the Gastroenterological Society of Australia, produced guidelines on bowel cancer screening. The guidelines concentrated on recommendations for groups with above-average risk but drew attention to the four randomised controlled trials on faecal occult blood testing (FOBT) that were in progress (1-4). In August 1993, the Australian Cancer Society (ACS) held a consensus conference in Sydney, subsequently setting up a joint AGI/ACS working party to produce up-dated guidelines. The outcome was a second edition of guidelines on early detection, screening and surveillance released in November 1994 with endorsement from a number of medical organisations.

The 1994 guidelines were issued after publication of the results of the Minnesota trial (1) and referred to the imminent release of results of the Nottingham and Funen trials (2,3). Although advising against immediate establishment of a national screening program based on FOBT, the recommendations called for substantial funding for pilot programs to assess implications and mechanisms of introduction of such a program .

At the same time, exciting progress was occurring in cancer genetics, greatly stimulating interest in the coming place of genetic testing for inherited bowel cancer. Familial polyposis registers were established in all mainland States, starting with Western Australia in 1985, followed by programs for HNPCC and for people with an intermediate levels of risk for the disease.

In 1995, in response to the growing consensus among medical experts, the Federal Minister of Health instructed the Australian Health Technology Advisory Committee (AHTAC) to establish a working party to advise her on screening for bowel cancer. The working party first met in mid-1995 and was well placed to incorporate the results of the Nottingham and Funen trials that were published in December 1996 (2,3).

The official AHTAC report was released by the Minister in March 1998 (5), the major recommendations being as follows:

1) "On the basis of published evidence, and subject to favourable preliminary testing, it is recommended that Australia develop a program for the introduction of population screening for colorectal cancer (CRC) by faecal occult blood testing (FOBT) for the average risk population (well population aged over 50)."

2) "Given the uncertainties relating to the most effective means of implementing such a program and to the feasibility, acceptability and cost-effectiveness of such a program in the Australian setting, the program should commence with preliminary testing involving a number of pilot and feasibility studies."

Establishment of pilot and feasibility studies

These studies should address a number of questions, including:

3) Cost-effectiveness, compliance rates and safety of varying the upper age limit of the population offered screening.

4) Investigation of the performance characteristics of various FOBTs, with recommendations for selection of types of test to be used in screening.

5) Investigation of the desirable frequency of testing (annual or biennial).

6) Investigation of quality assurance aspects of sample collection and laboratory testing of FOBTs.

7) Investigation of the best method of achieving high quality and efficient follow-up of positive FOBTs.

8) Investigation of organisational issues to determine the optimal method of for delivery of a screening program.

9) Studies on participation and compliance, cost effectiveness, assessment of adverse physical and psychological effects of the program, development of programs for education of the public and the medical profession, and evaluation of the success and acceptability of the pilot programs.

The report states that, at this time, there is insufficient evidence either to accept or reject screening for bowel cancer using modalities other than FOBT. Further investigation of alternative approaches should be encouraged but some of the planned pilot studies could assess the improvement in detection rate of significant lesions when other screening modalities such as flexible sigmoidoscopy are added to FOBT.

High risk population

The report also recommends that individualised programs of surveillance should be developed for those at high risk for bowel cancer. Plans need to be developed for nationally coordinated approaches for management of familial adenomatous polyposis and HNPCC.

Detailed plans for the proposed pilot studies have been drawn up. The next requirement is financial support to allow them to proceed. Having accepted the recommendations of the report, the Federal Government is likely to announce availability of funding later this year. The pilot studies will take 3-5 years to complete. By that time, it should be possible to launch a nation-wide screening program for bowel cancer. Watch this space!

REFERENCES

1. Mandel JS, Bond JH, Church TR, et al. Reducing mortality from colorectral cancer by screening for fecal occult blood. N Engl J Med 1993; 328: 1365-1371.

2. Hardcastle JD, Chamberlain JO, Robinson MHE et al. Randomised controlled trial of faecal-occult blood screening for colorectal cancer. Lancet 1996; 348: 1472-1477.

3. Kronborg O, Fenger C, Olsen J et al. Randomised study of screening for colorectal cancer with faecal occult blood test. Lancet 1996; 348: 1467-1471.

4. Kewenter J, Brevinge H, Engaras B et al. Results of screening, rescreening, and follow-up in a prospective randomized study for detection of colorectal cancer by fecal occult blood testing: results for 68,308 subjects. Scand J Gastroenterol 1994; 29: 468-473.

5. Colorectal Cancer Screening: a report of the Australian Health Technology Advisory Committee. Australian Commonwealth Department of Health and Family Services. Dec 1997.

Dieulafoy Disease. Endoscopic Diagnosis and Treatment

Introduction

Upper gastrointestinal bleeding is one of the most frequent and serious emergencies in occidental countries, responsible, in our environment, of 3% of hospital admissions.

Among the non varicous gastrointestinal bleeding, one of the rarest etiologies, and, at the same time, one of the severest, is Dieulafoy Disease, which represents less than 1% of all causes of gastrointestinal bleeding. With relative frequency, a certain confusion is observed when commenting this entity and that of the ulcer with visible vas, due to a lack of rigour in anatomic, endoscopic and clinical criteria in a large number of publications.

Ulcer with visible vessel. (Fig. 1) It is the ulcer showing, within its crater, a more or less round structure, of variable colour, ranging between mother-of-pearl, reddish and blackish, supposedly corresponding to the vas which has bled, and which may bleed again. Generally, it is impossible to distinguish endoscopically between the remaining of a vas (visible vas) and a clot sealing the vascular tearing point.

Dieulafoy Disease (DD). (Fig. 2) It is a concept which should be kept for digestive bleeding secondary to the tearing of a vas of abnormal thickness for the mucosal territory it lies in, tearing being due to a superficial erosion of the mucosa, as can be verifyied in the histopathologica study of cases undergoing surgery (Fig. 3). As Dieulafoy used to say, it is an "exulceratio simplex" of the upper layer of the mucosa. The endoscopist will see a vas with no ulcer around it, or a slight, sometimes pulsating bulge on the wall, with a central point of hemostasia. If there is an ulcer, it is wrong to talk of DD. For this reason the term " Dieulafoy ulcer" is not correct. Most DD are seen in the stomach, but it may be observed anywhere in the digestive tube territory.

Until few years ago, only surgical treatment was feasible, but at the present time communications of successful treatment are increasingly frequent. Our first favourable results in endoscopic treatment of DD were obtained in 1986, and were presented at the VI European Congress of Digestive Endoscopy, celebrated in Rome in 1988.

Aim

To evaluate the efficacy of endoscopic treatment of Dieulafoy Disease, both in a short and in a long term.

1. Selection of patients complying with the endoscopic criteria for hemorrhage due to Dieulafoy Disease, among all patients admitted because of upper gastrointestinal bleeding in our Hospital between November 1986 and May 1998.

2. Endoscopic treatment of patients with Dieulafoy Disease. During the first 3 years, patients were treated with injection of 1/10.000 adrenaline, 2% polidocanol and monopolar electrocoagulation. Since 1989, the treatment has consisted only in the use of adrenaline and polidocanol, administered in small injections in the bleeding point as well as around it.

Results

4.873 patients with upper gastrointestinal bleeding were studied, 33 out of which met criteria for Dieulafoy Disease, representing a 0.67% of cases. Endoscopic treatment was carried out in 32 patients (30 of gastric and 2 of duodenal location).

In one case, diagnosis of jejunal Dieulafoy Disease was achieved during a preoperatory endoscopy, and he did not receive endoscopic treatment. The combined method of injection of drugs + electrocoagulation was used in 8, and injection of drugs (1/10.000 adrenaline + 2% polidocanol) was used in 24. Only 4 our of the 32 patients needed subsequent surgery for the control of new bleeding episodes. In the other 28 (87.5%), hemorrhage was definitely controlled.

Moreover, none of these 28 patients has presented new gastrointestinal bleeding episodes since hospital discharge. No complications were observed in this series.

1. There is a good response to endoscopic treatment of gastrointestinal bleeding due to Dieulafoy Disease.

2. A combination of chemical an thermic agents is as effective as the use of chemical agents alone. The relevant issue is destruction of the area of the bleeding vas.

3. Long term results are also very satisfactory.

Laser Lithotripsy

Currently, more than 90% of all common bile duct concrements can be removed via the endoscopic retrograde route by means of endoscopic papillotomy, stone extraction by basket and balloon catheters, or mechanical lithotripsy. Oversized, very hard or impacted stones, however, often still resist conventional endoscopic therapy. Laser lithotripsy represent a promising new endoscopic approach to the nonsurgical treatment of those common bile duct stones.

In 1986, common bile duct stones could be disintegrated for the first time in man via the endoscopic retrograde route by means of pulsed Nd: YAG LASER (1,2). In the meantime, experience of other groups have been reported mostly applying the pulsed dye laser (3).

However, to date, only about 120 patients have been treated worldwide with this new therapy concept, which is still an experimental clinical treatment. Certain problems concerning the laser lithotriptor devices, the endoscopic approach and energy application in the bile duct account for this fact.

For clinical application in gastroenterology, the only laser systems at present commercially available are pulsed dye and Nd: YAG lasers.

The pulsed Nd: YAG laser is a solid state laser emitting near infrared light (usually 1064 mm wavelength). Two different pulse qualities are used for laser lithotripsy: ms pulses (10-3 s) generated in the free-running operation mode and ns pulses (10-9 s) generated in the O-switched operation mode.

The free-running mode Nd: YAG laser produces light pulses up to some thousands of watts in a period of 2 ms.

The light transmission system consists of a simple highly flexible 200 m quartz fibre brought into direct contact with the stone. After guiding the fibre with laser pulses of lower energy (0,5 J/4 Hz) to the centre of the stone, the pulse energy is augmented (1.3 to 2.0 J/4 Hz). In this way, even giant calculi can be disintegrated into two to five fragments within seconds (5 to 90 s). The fragmentation of high vapour pressures at the fibre tip which make the stone breakup from its centre. Due to relatively high pulse energies, discrete thermal lesions of tissue in contact with the 2000 m fibre tip are possible. However, chronic experiments in dogs showed no complications in clinical and laboratory follow-up until four weeks after direct irradiation of the bile duct. Histological findings after that time were basically normal (4).

With the Q-switched operation mode, the pulsed Nd: YAG laser, nonlinear optical processes such as "plasma" induction and creation of a locale shock wave can be induced. By this method, a completely athermal transformation of light energy into mechanical energy is possible (5).

Due to the high power peaks of the "giant pulses" of the
Q-switched Nd: YAG laser, initially only relatively rigid fibre transmission systems could be used. The fibre core diameter was at least 600 m and an additional lens focusing system of "light pipes" at the distal fibre end were needed (6).

Hochberger has developed a highly flexible 300 m quartz light guide system which permits endoscopic retrograde application of the Q-switched Nd: YAG laser (7).

The laser plasma at the point of the mechanical shock wave is induced either in front or directly on the surface of the concrement.

Stone disintegration results in the removal of very thin sand grain or power-like fragments from the stone surface. There is no hazard of thermal damage to tissue applying this laser type.

In the flash lamp pulsed dye laser, organic dyes mostly dissolved in alcohol are used as active laser materia.

Best light absorption in gallstones and kidney stone is obtained in the blue-green light spectrum (8). For this reason, 504 nm wavelength is commonly applied, which can easily and effectively be generated using cumarin dye and which is less absorbed in hemoglobin than in bilirubin. The high absorption of biliary concrements for light of this wavelength facilitates the induction of a laser plasma with the relatively long microsecond (10-6s) light pulses of the dye laser. The fragmentation process itself is athermal, but induced by a thermal process (9,10).

After beating a small quantity of stone material at the rip of a 200 m fibre brought into direct contact with the stone surface, the plasma and consequently, the mechanical shock wave is induced.

The results of fragmentation is similar to that of the Q-switched Nd: YAG laser. The advantage of the dye laser lies in its simple fibre transmission system, corresponding to that of the free-running mode Nd: YAG laser an the use of low pulse energies (Ep 30 to 90 mJ; Pm 0.3 to 1.3 W). Contrary to the nanosecond pulse Q-switched Nd: YAG, the dye laser can induce thermal tissue damage.

At present, there are three different methods for endoscopic retrograde application of laser lithotripsy in the common bile duct (2).

If the stone can be cause in the lithotripter basket, it can be fragmented under x-ray control alone; the fibre is centered right in the middle of a laser basket by means of a central channel without any risk of accidental application of energy to surrounding tissue.

In the case of impacted stone, a similar idea is pursued using a balloon catheter with a central channel. The safest approach for stone fragmentation is the use of a "baby" or "mini" endoscope which is inserted into the bile duct via a "motherscope".

The reason which speaks in favour of laser lithotripsy compared to extracorporeal shock wave litrotripsy (11) is that laser lithotripsy can be executed in any endoscopy unit in the aim of endoscopic pretreatment, usually necessary for extracorporeal shock wave lithotripsy (contrast x-ray, papillotomy and insertion of a nasobiliary tube). Furthermore, laser lithotripsy is painless and therefore, does not require general anesthesia or additional medication besides the usual endoscopic retrograde cholangiopancreatography.

Complications in the clinical use of laser lithotripsy have not been reported so far as in electrohydraulic lithotripsy.

REFERENCES

1. Parisi A.F., Nieminen M., O’Boyle J.E. Enhanced detection of the evaluation of tissue changes after acute myocardial infarction using colour encoded two dimensional echocaridography. Circulation 1982; 66: 764-770.

2. Lux G., Ell C., Hochberger J., Muller D., Demling L. The first successful endoscopic retrograde laser lithotripsy of common bile duct stones in man using a pulsed neodymium YAG-laser. Endoscopy 1986; 18: 144-145.

3. Kozarek R.A., Low D.E., Ball T.J. Laserlithotripsy of large bile duct stones. Gastrointest Endosc 1986; 28: 144-145.

4. Ell C., Hochberg J., Muller D., et al. Laserlithotripsy of gallstones by means of pulsed neodymium YAG-lager – In vitro and animal experiments. Endoscopy 1986; 18: 92-94.

5. Boulnois J. : Photophysical process in recent medical laser developments: A review, Lasers Med Sci 1986; 1: 47-66.

6. Ell C., Wondrazek F., Hochberger J., Lux G., Demling L. Laser-induced shockwave lithotripsy of gallstones. Endoscopy 1986; 18: 144-145.

7. Hochberger J., Ell C., Gruber E., et al. Laserlithotripsy of biliary calculi by means of a Q-switched giant pulse Nd: YAG laser and highly flexible fiber systems. Gastroenterology 1986; 95: A213 (Abst.).

8. Nishioka N.S., Levins P., Murray S., Parrish J., Anderso R. Fragmentation of biliary calculi with tunable dye lasers. Gastroenterology 1987; 93: 250-255.

9. Tio T.L., Wijers O.B., Sars P.R.A., Tytgat G.N.J. Preoperative TNM classification of proximal extrahepatic bile duct carcinoma with endosonography. Semin Liver Dis 1990; 10: 114-120.

10. Dukes C.E., Bussey H.J.R. The spread of rectal cancer and its effect on prognosis. Br J Cancer 1958; 12: 309-320.

11. Sauerbruch T., Stern M. Fragmentation of bile duct stones by extracorporeal shock waves. Gastroenterology 1989; 96:146-152.

The experts in Terminology Meet in Rome, Italy, on May 1-2, 1998 under the Auspices of OMED, ASGE and ESGE

Version 2.0: Rome 1998

For over 20 years endoscopists in the United States and Europe have struggled to create a standard lexicon in digestive endoscopy. The efforts of hundreds of gastroenterologists from many countries and institutions culminated in the review and approval of the Minimal Standard Terminology version 2.0 in Rome, Italy. The importance of the MST 2.0 is not simply that for the first time the endoscopic community has agreed on a series of terms to define more precisely endoscopic observations. In fact, this activity has demonstrated the globalization of endoscopy and the impact of information system technology on the ability to integrate the interests of the international endoscopic community.

Terminology has been an issue in all corners of the globe. The OMED Committee on Terminology led by Professor Z Mar?atka began work on an endoscopic lexicon in 1978. The OMED Terminology is the most comprehensive list of endoscopic descriptive terms. The ASGE began its efforts in 1982 with the creation of the ad-hoc computer committee chaired by Dr. J Geenen and implemented by Dr. D Kruss. The result of this activity was the creation of the ASGE database which was the combination of a lexicon and software implementation that led to the creation of several large databases of endoscopic reports. These efforts did not gain widespread acceptance and in 1991, the ESGE undertook an effort under the leadership of Dr. M. Crespi to create the Minimum Standard Terminology. Participants form the ESGE, the United States and Japan met over the course of three years to produce the first version of the MST. The group set out several basic principles:

• the lexicon should consist of the most commonly used terms in endoscopy,

• the lexicon should follow a concept-modifier model,

• redundant and synonymous terms should be eliminated

• the lexicon should not specify software function but povide the lists needed for software development around a standard.

It was not sufficient to simply publish this lexicon but it was necessary to test the degree to which the MST could be used to describe endoscopic findings. Testing of the MST 1.0 was begun simultaneously in Europe and the United States. Approximately 20 centers in 12 countries produced over 25,000 endoscopic procedure reports. These results were reviewed in joint meetings between the ASGE, ESGE and Japanese Endoscopic Societies. Terms that occurred less that <0.1% were excluded and the section on ERCP was revised to reflect the complexity of this procedure. The ERCP revisions were designed to take into account the combination of maneuvers and observations that are made during the procedure. For example, a sphincterotomy may be done in order to cannulate the papilla and then visualize the duct. This is different from colonoscopy where maneuvers such as polypectomy are done based on the findings observed. The MST version 2.0 was completed after meetings in Rome of the Committee on Terminology and in New Orleans at Digestive Disease Week.

The Rome meeting on Minimum Standard Terminology version 2.0 was an important first step toward the development of an International Lexicon of Endoscopy. The unique collaboration between Gastrointestinal Endoscopic Societies has been recognized by the World Health Organization (WHO) as a model for international medical cooperation. The next steps for dissemination of this lexicon include:

• support of the GASTER project designed to create a textual and visual dictionary to accompany the lexicon,

• testing of the terminology in Japan, an effort led by Dr. Ogoshi and Dr. Fujino,

• development of a conformance statement that enables purchasers of endoscopic software to determine the extent to which the MST is used,

• introduction of the MST as a part of SNOMED International, the largest medical lexicon.

• development of a Web-based mechanism to support revision and modification of the MST.

MST version 2.0 is edited by Dr. M. Delvaux and Dr. L. Korman. Each national endoscopic society will have the opportunity to translate the MST directly from the International Version. The national language version should be reviewed and approved by that society and then locally disseminated. Proposed changes and extensions to the MST will go through an editorial review process governed by the OMED Committee on Terminology and the Editors of the MST. This process will ensure that the MST is maintained and responsive to the needs of the International Endoscopic community. The further development MST will provide a standard for research and clinical care that will assure that our patients receive the highest quality of care.

Chromoendoscopy

The colonic mucosal surface, on close observation, is granular in appearance and demarcated into small areas called non specific grooves. When a blue dye such as indigo carmine or methylene blue is sprayed on the surface, the grooved pattern becomes clearly observable. In figure 1, the normal grooved pattern shows a regular arrangement.

Figure 2A shows a flat early cancer detected in the transverse colon by the finding of interruption in the vascular pattern. The extent and the surface structure of this lesion can not be clearly seen. By spraying the mucosa with a blue dye (indigo carmine), the extent and the minute surface structure of this lesion becomes clearly seen, which is not possible with conventional colonoscopy (Figure 2B).

Chromoendoscopy has been developed specifically in Japan since the 1970s and many Japanese endoscopists now routinely use this technique. However, despite data suggesting a clinical role for chromoendoscopy, this technique appears to be rarely applied in clinical practice in other countries. Herein I explain how we use this technique in Japan and its effectiveness in clinical practice.

Chromoendoscopy uses chemical compounds as stains or contrast agents to highlight subtle mucosal surface changes or abnormal gastrointestinal epithelium. Three basic types of chromoendoscopy are employed in gastrointestinal endoscopy at the present time and called the contrast, staining and reaction methods.

The contrast method highlights irregularities in the mucosal architecture by pooling of a blue dye solution in mucosal grooves and other interstices. This improves the precision of endoscopic diagnosis by defining minute and inconspicuous lesions that might otherwise be overlooked with conventional endoscopy. There are two methods of performing contrast chromoscopy, direct and indirect. In the direct method, the dye is applied under direct vision and is suitable for investigating lesions that have already been detected. With the indirect method, the dye is delivered either orally or anally and is effective specifically in the detection of lesions and lowers the possibility of their being overlooked.

The dye most frequently used for contrast chromoscopy is indigo carmine, the food additive known as Food blue No. 2. It has an acceptable daily intake of 2.5 mg/Kg body weight and is so poorly absorbed from the alimentary tract that it can safely be used for chromoendoscopy.

Indigo carmine does not actually stain the surface of the mucosa, as in the staining method, and can easily be washed away with water. Consequently, the dye can be applied any number of times with ease.

The staining method is based on the absorption of dye by epithelial cells, or permeation of the dye into necrotic tissue. It is a more specific method of chromoendoscopy, since the dye absorptive function of the mucosa or various lesions can be evaluated by endoscopy.

The staining method can be used to diagnose certain diseases, pathologic conditions, and mucosa states that are difficult to recognize with certainty using conventional endoscopic observation. Two examples are gastric intestinal and the state of the colonic mucosa in ulcerative colitis, to confirm whether the inflammatory process is active or healed. Methylene blue is the dye most frequently used for the staining method. In the reaction method, a dye applied to the mucosal surface reacts with a constituent of the epithelial cell or some mucosal secretion. There are two types, the Lugol method and the Congo red method.

Non-keratinized squamous epithelial cells contain abundant glycogen which reacts with Lugol’s solution. This reaction has been used to diagnose esophageal diseases such as esophagitis and carcinoma.

The Congo red method is based on the reaction that occurs between this dye and secreted hydrochloric acid. It is therefore used in defining the extent of the acid secretion in normal fundic mucosa. Using this method, the color of the normal fundic mucosa changes from red to dark blue, while the antral mucosal surface does not change color. As a result, this method is not suitable for morphologic observation.

Blue dyes, such as indigo carmine and methylene blue, are the most suitable for observation of gastrointestinal morphology and staining phenomena, because the blue color contrasts sharply with the reddish mucosa. Lugol’s solution and Congo red are also useful for certain purposes as explained above. Although almost no side effects from dyes used in chromoendoscopy have been reported, only the minimal amount of dye solution required for examination should be used. At the conclusion of the procedure any remaining pools of dye should be aspirated.

The following is a discussion of chromoendoscopy for each organ in an actual clinical setting.

Lugol staining is specifically used for the esophagus. After direct spraying with Lugol’s solution, normal esophageal mucosa is stained brown or dark brown and has a fine mucosal pattern suggesting a wrinkled texture. Esophageal cancer and esophagitis are not stained by Lugol’s solution. Therefore, this method is useful for detecting early cancer and defining the boundaries of invasive cancer.

The contrast method using indigo carmine is frequently used for the stomach and duodenum. The contrast method is very effective in detecting early gastric cancer and in recognizing the extent of cancer infiltration in the mucosa (Figure 3A, B).

This method is also useful to differentiate benign from malignant ulcers and may aid in determining whether or not an ulcer is recurrent. Early gastric cancer are not only difficult to detect endoscopically but also, when discovered, their true nature may not be recognized. With the contrast method however, it is not difficult to recognize such lesions and define their size, shape, number and distribution.

The villous pattern of the duodenum and individual villi are clearly defined by the contrast method. This method is helpful in determining whether a duodenal ulcer has healed completely and also in demonstrating a rare duodenal malignancy more clearly.

The contrast method and the staining method are specifically used for colonoscopy, but the contrast method is more popular than staining because of its ease of use and repeatability.

Colonic lesions originating form mucosa (except for submucosal tumor) are so certain to have a different surface pattern from the normal grooved one that it is not only easy to detect such lesions interrupting the grooves but it is also possible to investigate them more meticulously when using chromoendoscopy.

Figure 4 shows a flat elevated invasive cancer, 12 mm in size, detected in the ascending colon. The extent of this lesion can be recognized, but its surface structure can not be clearly seen. The contrast effect by indigo carmine spraying helps to visualize the non-specific grooves, and it is easy to recognize the extent of the lesion more clearly. In addition, the thin coating of the dye that remains on the surface clearly reveals the depressed part of the lesion that can not be seen through conventional colonoscopy. The existence of the depressed part and the magnified observation of the irregular surface pattern here cause us to highly suspect this lesion’s malignancy.

Dye spraying is an indispensable item for magnified observation.

After an endoscopic mucosal resection was performed for this lesion, magnified observation combined with an application of the dye was performed to check for any residual lesions at the resected margin. Using chromoendoscopy and magnified observation we can accomplish a more thorough endoscopic treatment.

Figure 5 is a diminutive flat adenoma. Methylene blue stains the normal mucosa around the lesion, but not the lesion itself. The staining differences between the lesion and normal mucosa are very useful for demonstrating the extent of the lesion. Methylene blue can be also used in the contrast method before tissue staining is completed in the several minutes during which this blue dye is scattered on the surface of gastrointestinal tract..

The technical difficulty of chromoendoscopy is minimal. There is a learning curve for endoscopic procedures, but proficiency in chromoendoscopy is usually attained with relatively few examinations. Cost and inconvenience is negligible. Most chromoendoscopy techniques add only several minutes to the length of an endoscopic procedure and most dyes are inexpensive (a few dollar for indigo carmine, methylene blue, or Lugol’s solution).

Chromoendoscopy improves the quality of gastrointestinal endoscopy, resulting in a degree of diagnosis and treatment that has heretofore not been possible with conventional endoscopy.

All patients undergoing endoscopy do not necessarily require chromoendoscopy.

The indications for chromoendoscopy are dependent upon each endoscopist who understands its clinical effectiveness. I propose that all endoscopists should learn chromoendoscopy as an optional endoscopic technique and be able to use it whenever necessary in actual clinical settings.

Fibrin Sealant: Endoscopic Indications and Results

Fibrin sealant is an agent widely used in many surgical disciplines for achieving hemostasis and tissue adhesion. During the last steps of normal physiological coagulation, hemostatic clots are formed which mainly consist of erythrocytes, thrombocytes and fibrinogen. The subsequent conversion of fibrinogen to fibrin monomers by thrombin in the presence of calcium ions and factor XIII leads to formation of a stable fibrin clot. Later, as wound healing progresses, fibrinolytic activity is induced by plasmin and breakdown of fibrin to fibrin degradation products takes place.

The hemostatic effects of fibrin sealant are an initiation of the last steps of physiologic blood coagulation. As soon as the two components fibrinogen and thrombin, for instance via a double lumen catheter come in contact with each other, fibrinogen is converted to fibrin by the action of the thrombin-component.

Fibrin sealant is used by gastroenterologists and surgeons for bleeding control, tissue adhesion, suture support, wound care and sealing of fistulae.

Fibrin sealant and Ulcer Bleeding

Persistent or recurrent bleeding occurs in about 20% of the patients presenting with a bleeding ulcer. In this group of patients, the mortality rate is still 11-14%. The morbidity and mortality rates are higher in patients with ulcers with endoscopic signs of recent hemorrhage.

These patients account for the majority of patients that require additional interventions. In Europe the most common technique used is subulcerous injection with epinephrine followed by sclerotherapy with 1% polidocanol. In around 10-20% of patients in whom hemostasis is achieved further bleeding will occur. In case of rebleeding repeated injection of a sclerosing agent will lead to more extensive ulceration with the risk of fatal rebleeding or perforation.

Injection of thrombin only or of fibrin sealant instead of epinephrine /polidocanol has been studied as single-injection therapy, and as repeated injection therapy. Thrombin and fibrin sealant causes only very limited tissue damage and can therefore be injected ad libitum and can be repeated. Also fibrin sealant forms a natural matrix for wound healing, whereas sclerosing agents cause thrombosis and further ulceration. Recently a randomized trial was published, comparing the safety and efficacy of repeated fibrin sealant injection and of single endoscopic injection of polidocanol in the prevention of rebleeding (1). A total of 854 patients with active gastroduodenal ulcer bleeding (spurting, oozing), or ulcers with a visible nonbleeding vessel, were randomized to one of the three endoscopic treatments: single application of 1% polidocanol, single application of fibrin sealant, or daily repeated application of fibrin sealant until the visible vessel had disappeared. All patients were pretreated with local injection of epinephrine (1:10.000) and underwent daily endoscopies until the signs of recent hemorrhage were not longer visible. Rebleeding rates among the patients in whom the rates could be assessed were 58 of 254 (22.8%) in the polidocanol group, 51 of 266 (19.2%) in the fibrin sealant-single group, and 41 of 270 (15.2%) in the fibrin sealant-repeated group. The difference between fibrin-repeated treatment and polidocanol 1% was significant (p=0.036). Treatment failures, making other treatments necessary (including surgery) were 34 of 261 (13.0%) in the polidocanol group, 34 of 274 (12.4%) in the fibrin sealant-single group, and 21 of 274 (7.7%) in the fibrin-repeated group. The difference between fibrin sealant-repeated treatment and polidocanol 1% was significant (p=0.046). The 30-day mortality rates and safety profiles of the three treatment strategies were similar. It was concluded that repeated injection of fibrin sealant is significantly more effective than injections with 1% polidocanol in the treatment of bleeding gastroduodenal ulcers. The lack of tissue damage and safety of fibrin sealant allows repeated injections until the ulcer base becomes clean or until the visible vessel is reduced to a flat brown spot. Probably the most important factor in hemostasis is complete obliteration of the feeding vessel. A single application sclerosing agent or a single treatment of thermal coagulation may not be effective enough, but the risk of extensive tissue necrosis and even perforation makes endoscopists reluctant to repeat these treatment modalities in case of rebleeding. Repeated injections of fibrin sealant however can be given without risk for further tissue damage, and are effective in vessel obliteration. A double lumen catheter is used for the injection of 1 ml fibrin sealant, which is flushed out of the catheter by 1 ml 0.9% saline.

Fibrin sealant and Fistulae

Because of the good biological properties including wound healing, fibrin sealant is used for closure of persistent bronchopleural fistulae, tracheo-esophageal fistulae, leaking duodenal stumps after surgery, peripheral bile leaks after liver resection etc. Groitl et al (2) reported on 84 patients with postoperatively leaking anastomoses treated with endoscopic application of fibrin sealant. After thorough cleaning of the fistula or abscess cavity, the fibrin sealant was applied. Usually several sessions were required, but finally 82% of proximal G I-and 61% of lower G I-tract leaks or fistulae were successfully closed. Eimiller (3) reported on 22 patients with Crohn’s disease and fistulae. In almost all patients rectovaginal, enterovesical, entero-entero and entero-cutaneous fistulae were successfully closed with only 17% recurrences.

Ambrose et al (4) treated 13 patients with persistent perineal sinus after proctectomy for inflammatory bowel disease or cancer. Previous attempts to close the sinus ranged from none to four revisions (mean 2.2). In four patients the sinus had subjectively improved and healed completely in 5 patients without recurrence in 129 patient months of follow-up. The authors suggest in view of the simplicity of the procedure and its low morbidity, it should be tried before embarking on major surgical procedures.

We were successful in closing postoperative leaks after esophago-cardial resection in 6 out of 8 patients, usually after one single application. Only small fistula with a diameter of less than 0.5 cm were considered candidates for this technique.

Engler et al (5) reported endoscopic occlusion with fibrin sealant of a persistent pancreatic fistula after acute pancreatitis. In three sessions over 6 days, 1-2 ml fibrin sealant injections were applied by ERCP into the fistula tract leading to complete occlusion without any further complication.

We recently treated a patient with a biliovenous fistula after percutaneous liver biopsy. Normally such a fistula closes spontaneously after a few days, but in this patient a dominant extrahepatic stricture due to primary sclerosing cholangitis prevented spontaneous closure. Due to the pressure gradient bile leaked into the venous system leading to extreme jaundice with a serum bilirubin of more than 2000 µmol/l (117 mg/dl). Superselective cannulation by ERCP of the leaking peripheral bile duct and subsequent injection of fibrin sealant closed the fistula immediately, with rapid decrease in serum bilirubin (6).

Data from the literature warrant further widespread application of fibrin sealant for several indications, like post-operative leaks, fistulae, and ulcer bleeding.

REFERENCES

1. Rutgeerts P, Rauws EAJ, Wara P, Swain P, Hoos A, Solleder E, Halttunen J, Dobrilla G, Richter G, Prassler R. Randomised trial of single and repeated fibrin glue compared with injection of polidocanol in treatment of bleeding peptic ulcer. Lancet 1997; 350: 692-696.

2. Groitl H, Horbach T, Stangl R, Scheele J. Endoskopische Applikation von Fibrinkleber zur Behandlung von Anastomosen insuffizienzen, Perforationen und Fisteln im Gastrointestinaltrakt. In: Technik der Fibrinklebung in der Endoskopischen Chirurgie. Manegold BC, Lange V, Salm R (Eds). Springerverlag 1994; 85-91.

3. Eimiller A. Endoskopische Fibrinklebung zur Behandlung von Fistula bei Morbus Crohn. In: Technik der Fibrinklebung in der endoskopischen Chirurgie. Manegold BC, Lange V, Salm R (Eds). Springer-Verlag 1994; 103-105.

4. Ambrose NS, Alexander-Williams J. Appraisal of a tissue glue in the treatment of persistent perineal sinus. Br J Surg 1988; 75: 484-485.

5. Engler S, Dorlars D, Riemann JF. Endoskopische Fibrin verklebung einer Pankreas gangfistel nach akuter pankreatitis. Dtsch Med Wschrochenschr 1996; 121: 1396-1400.

6. Sattawatthamrong Y, Janssens AR, Alleman MJA, Huibregtse K, Rauws EAJ, Tytgat GNJ. Endoscopic treatment of bilhemia following percutaneous liver biopsy (submitted).

Survey on Endoscopic Practice in Africa

Introduction

When we consider endoscopy in Africa, 3 points are of relevance:

• An important delay in comparison with North America and Western Europe in implementing endoscopy, and in the introduction of the new instruments and accessories.

• A great inequality between geographic areas and countries.

• Existence of two areas, with differences in terms of approach to endoscopy: the anglophone area and the francophone one.

Who performs endoscopy?

In most of a cases, physicians, specialized in gastroenterology are allowed to practice endoscopy, but in Egypt and South Africa, surgeons, general practitioners and occasionally poediatricians perform the procedure.

Training and maintaining competence:

There is no special diploma for performing endoscopy. The medical school by the means of University hospitals offers 3-4 year-training programs in gastroenterology, including endoscopy. An applicant must complete the two years residency in internal medicine prior to the admission to to gastroenteroloy diploma.

Training is done through practical medical education, conducted by seniors in University hospitals, and endoscopy Units, by the means of a teaching attachment when fiberoptic endoscopes are used, or by video if available. No threshold number of G.I. endoscopy procedures is required to achieve initial competence Diagnostic procedures for upper and lower gastrointestinal tract are widely learned, while operative endoscopy and new techniques are usually reserved for senior endoscopists working in University hospitals . In Egypt, to practice endoscopy, one should have completed a certificated training course (usually 6-12 months) in a well known G.I. endoscopy Center. At the end of the course a final evaluations achieved through a special form and questionnaire. The trainee should be approved by Medical Societies and the Medical Egyptian Syndicate. Besides the practical aspect, the training includes, lectures, symposiums, annual conference, and workshops. The "credit hours system" is absent, except in South Africa where there is a CME program with points being allocated for attending lectures, workshops, tutorials, etc.

Compliance with the C.M.E. program by the year 2000 will affect all the registred gastroenterologists.

Endoscopy Units

Diagnostic endoscopy is carried out in hospitals and private practice. Guidelines for G.I. unit are absent but in fact they exist in training hospitals with good standards.

Endoscopy units of reference

Are unusual and are located in the University Hospitals, well equipped, with different rooms for each procedure, good maintenance, sedation and disinfection. They are the elective areas for operative endoscopy. In south Africa, there is a managed two years career registrar program in all the teaching units. On completion they are required to perform an examination and submit evidence of attendance to courses and completion of activities.

Elsewhere, usual endoscopy for upper and lower G.I. tract in widely carried out even in private practice.

Material

The nonimmersible endoscopes are absolete, and are not used any more. The fiberoptic endoscopes are the majority while videos, are rarely available.

Type of examination

If all the endoscopists are allowed to carry out upper and lower G.I. endoscopy, the operative endoscopy is reserved to the experienced endoscopists in the University Hospitals or specialized centers.

The instruments for echo endoscopy are very few, while endoscopic surgery is increasing dramatically.

Indications and informed consent

Usual endoscopy is carried out, after a clinical examination, almost without explanations, or informed consent, except in South Africa and in the Egyptian University Hospitals. In fact, the patient asks for care, voluntarily, and his frequent low education level doesn’t permit discussion. We have also to keep in mind that guidelines prepared for one community are not necessarily applicable to others, regarding the differences in approach due to the geography, race, social class, ethnic background, education, local referral patterns, and sophistication of local endoscopy services.

Sedation

Upper G.I. endoscopy, the most frequent examination, is carried out without any sedation, or topical pharyngeal anesthesia, in outpatient basis. This attitude is well accepted by the patients, allowing saving of time which is not a negligible aspect of endoscopy in developing countries. Diagnostic colonoscopy is also frequently carried out with spasmolytics only and sedation is reserved to emotional people, or when theraphy is needed like polypectomy which is rarely needed, except in the schistomas infection areas. All the other operative techniques are always carried out with sedation and monitoring on an inpatient basis. A report is always written for each patient.

Disinfection

Due to the low number of endoscopes and the enormous number of endoscopies needed, time for disinfection is very short, so that it still remains the "Heel of Achilles"of endoscopy in Africa. For a long time, it consisted in wiping the endoscope with a sponge and soap, followed by water aspiration and air insufflation, despite the high prevalence of virus (HIV-HBV), bacterias, and parasites. Moreover up to a recent date the endoscopes were kept in their case at the end of the session without banging for night. The lack of guidelines contributes to this situation. But the latter has been changing quickly for approximately 5 years and standards of disinfection are increasing. Automated systems were bought recently for equipping some centers of reference. In our Unit in Tunis, in South Africa and some places in Egypt the disinfection is done with standards accepted abroad. We have to keep in mind, that manual cleaning of the material is the most important step of disinfection.

The reuse of the accessories is a crucial point. Of course, sclerotherapy needles are never reused, while sphincterotomies, biopsy forceps, and disposable material are reused considering their cost and restricted availability.

Quality assurance

Objective evaluation of competence, and technical skills in G.I. Units is absent, related to the lack of license for performing endoscopy, the small number of endoscopists and endoscopy Units. It is very difficult, at the moment, to have supervisors for evaluating the endoscopist’s skills, the endoscopic units standards, and the examination quality.

The reduced availability of endoscopes is related to their high cost.

Perhaps it will be possible to lower the price, by reducing, or better by abolishing the import customs duties (like in Tunisia) or by manufacturing fiberoptic endoscopes cheaper.

The maintenance difficulties

– Disinfection: In the absence of guidelines and laws? It is our duty to address great efforts in this direction by establishing guidelines and adequate legislation.