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Physicians Update

 
Fall 2011

Broad Range of Endoscopic Procedures Emerging as Major Nonsurgical Interventions

10/27/2011

Endoscopic TechniqueAt major medical centers, an increasing number of gastrointestinal illnesses are being diagnosed and treated through the nonsurgical approach known as interventional endoscopy.

“Many procedures that were once the domain of the surgeon can now be done in a more minimally invasive way,” says V. Raman Muthusamy, M.D., associate clinical professor of medicine at the David Geffen School of Medicine at UCLA and director of interventional endoscopy, a newly created position within UCLA Health that reflects the field’s emergence.

“Through the endoscope we can now perform biopsies, resect precancerous and early cancerous lesions, inject substances to relieve pain or provide anti-tumor therapy, deliver cautery and even seal up small holes,” explains Dr. Muthusamy. “We are covering the full spectrum of digestive diseases through a broad set of endoscopic techniques that, in some ways, are approaching surgical capabilities.”

Some early-stage cancers and polyps that would have previously required surgical removal are now often treated endoscopically, Dr. Muthusamy says, through a technique called endoscopic mucosal resection. In some advanced cancers, stents can relieve obstructions for patients with tumors blocking the gastrointestinal tract. Interventional endoscopists are accessing the bile duct and pancreas to remove gallstones or overcome obstructions that might otherwise require surgical exploration. The small bowel, the area between the stomach and the colon, was historically difficult to access with endoscopes; now, through a new device, Dr. Muthusamy and his interventional endoscopy colleagues are able to perform a procedure called spiral enteroscopy, enabling them to go deep into the small bowel to treat disorders in that area.

Similarly, Barrett’s esophagus with dysplasia was a condition that often required surgical removal of the esophagus to head off the development of cancer; now in many cases interventional endoscopists are able to use their instruments to resect, burn or freeze away the affected cells and prevent the development of cancer and the need for surgery.

Endoscopy is also being used to treat other gastrointestinal disorders. With endoscopic ultrasound — a procedure that combines endoscopy with ultrasound imaging to create more detailed pictures — a patient suspected of having a pancreatic tumor, for example, can be diagnosed and biopsied, the tumor can be staged, and the nerves innervating the pancreas can be injected through the endoscope to relieve pain.

UCLA has also begun to use endoscopy to improve the results of bariatric weight-loss surgery. More than 2-million people in the United States have undergone such surgeries, most commonly in the form of gastric-bypass procedures, which create a small upper pouch that is reconnected to the small intestine as a physiological and psychological strategy for reducing food intake. But a large percentage of these patients begin to regain weight after a period of time, in part because their surgically created gastric pouch begins to stretch, allowing for increased consumption.

For the past year, interventional endoscopist Rabindra R. Watson, M.D., has been involved in the development of techniques that improve the surgical outcome by reducing the volume of the pouch endoscopically.

NonSurgical Care Endoscopic techniques offer several advantages over surgery, notes Dr. Watson, who joined UCLA’s growing group of interventional endoscopists in September. These advantages include fewer complications, faster recovery times, the ability to combine and tailor diagnostic and therapeutic procedures to patients’ needs, and the fact that the interventions are reversible. For example, Dr. Watson is currently engaged in research to use an endoscopic technique not just to improve the results of gastric-bypass surgery but as a primary procedure for bariatric surgery. In addition to being significantly less invasive, the approach, which Dr. Watson and colleagues hope to bring to clinical trials in the near future, could be used to assist patients in their initial weight-loss and diabetes-control efforts, with patients eventually being returned to their original anatomy.

Plans call for UCLA’s growing practice to include several interventional endoscopists working in conjunction with other surgical and medical teams to provide the most effective and least invasive care tailored to each patient’s circumstances. In addition to patient care, the program will train future interventional endoscopists, while serving as a focal point for the development and testing of new techniques and technologies.

“We were once distinct entities, black and white, and increasingly we are morphing into shades of gray,” Dr. Muthusamy says of interventional endoscopists and gastrointestinal surgeons. As the two disciplines meet near the middle, he adds, new opportunities for collaboration will arise. Dr. Muthusamy also foresees his program working closely with medical and radiation oncologists as endoscopic techniques continue to become more important to the diagnosis and treatment of GI cancers.

“Endoscopy represents a natural progression of medicine and technology,” Dr. Watson says. “We went from performing surgery through large incisions to the keyhole incisions of laparoscopy. The next step is doing things through endoscopy that we couldn’t have done before, thanks to new technology, new devices and the refinement of endoscopic skills.”

To watch a video about interventional endoscopy, go to: http://streaming.uclahealth.org/endoscopy





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