Endoscopic foregut surgery and interventions: The future is now. The state-of-the-art and my personal journey

Abstract

In this paper, I reviewed the emerging field of endoscopic surgery and present data supporting the contention that endoscopy can now be used to treat many foregut diseases that have been traditionally treated surgically. Within each topic, the content will progress as follows: “lessons learned”, “technical considerations” and “future opportunities”. Lessons learned will provide a brief background and update on the most current literature. Technical considerations will include my personal experience, including tips and tricks that I have learned over the years. Finally, future opportunities will address current unmet needs and potential new areas of development. The foregut is defined as “the upper part of the embryonic alimentary canal from which the pharynx, esophagus, lung, stomach, liver, pancreas, and part of the duodenum develop”. Foregut surgery is well established in treating conditions such as gastroesophageal reflux disease (GERD), achalasia, esophageal diverticula, Barrett’s esophagus (BE) and esophageal cancer, stomach cancer, gastric-outlet obstruction, and obesity. Over the past decade, remarkable progress in interventional endoscopy has culminated in the conceptualization and practice of endoscopic foregut surgery for various clinical conditions summarized in this paper. Regarding GERD, there are now several technologies available to effectively treat it and potentially eliminate symptoms, and the need for long-term treatment with proton pump inhibitors. For the first time, fundoplication can be performed without the need for open or laparoscopic surgery. Long-term data going out 5-10 years are now emerging showing extended durability. In respect to achalasia, per-oral endoscopic myotomy (POEM) which was developed in Japan, has become an alternative to the traditional Heller’s myotomy. Recent meta-analysis show that POEM may have better results than Heller, but the issue of post-POEM GERD still needs to be addressed. There is now a resurgence of endoscopic treatment of Zenker’s diverticula with improved technique (Z-POEM) and equipment; thus, patients are choosing flexible endoscopic treatment as opposed to open or rigid endoscopy options. In regard to BE, endoscopic submucosal dissection (ESD) which is well established in Asia, is now becoming more mainstream in the West for the treatment of BE with high grade dysplasia, as well as early esophageal cancer. In combination with all the ablation technologies (radiofrequency ablation, cryotherapy, hybrid argon plasma coagulation), the entire spectrum of Barrett’s and related dysplasia and early cancer can be managed predominantly by endoscopy. Importantly, in regard to early gastric cancer and submucosal tumors (SMTs) of the stomach, ESD and full thickness resection (FTR) can excise these lesions en-bloc and endoscopic suturing is now used to close large defects and perforations. For treatment of patients with malignant gastric outlet obstruction (GOO), endoscopic gastro-jejunostomy is now showing better results ...

Lesion size and circumferential range identified as independent risk factors for esophageal stricture after endoscopic submucosal dissection

“…Although ESD has become the leading treatment for early esophageal lesions, the occurrence of postoperative stricture has a significant influence on overall prognosis [8]. Generally, esophageal stricture occurs within 3 weeks after ESD, and the 6-month follow-up is sufficient for the observation of patients.…”

Hybrid Argon Plasma Coagulation for Treatment of Gastric Intestinal Metaplasia

“…It is a modification of standard APC that combines the application of APC with the ability to create a submucosal injection through the same catheter. It was initially developed for the ablation of refractory Barrett's mucosa and is now being used for the ablation of residual dysplastic or neoplastic tissue following endoscopic resection [13,14].…”

“…Hybrid argon plasma coagulation (HybridAPC® [HAPC]) is a novel ablation technique where the application of APC is preceded by a high-pressure needleless submucosal injection of saline. This is accomplished via a built-in water jet within the same catheter as the APC channel [14]. HAPC is indicated for the management of Barrett's esophagus; however, we are describing a novel use of HAPC in the treatment of gastric intestinal metaplasia with dysplasia [15].…”

Introductory Chapter: Endoscopy and ERAS

“…The illuminant of endoscope lights the cavity or tract of human body or organs, changes the managements of kinds of diseases, and benefits patients with minimally invasive approaches. Finally, I hope to introduce the appliance of endoscopic and laparoscopic procedures in digestive system via endoscopy and make the examinations and treatments more minimally invasive and effective [33][34][35][36].…”