As lines between endoscopy and surgery blur, division’s team continues to advance the field

Endoscopist putting on gloves

Interventional endoscopy has grown rapidly in recent years, emerging as the preferred procedure for diagnosing and treating many GI conditions that were once the domain of surgery given advantages that include fewer complications, quicker recovery times, the ability to combine and tailor procedures to patients’ needs, and the fact that the interventions can be reversible. At UCLA, the three members of the interventional endoscopy team within the Vatche and Tamar Manoukian Division of Digestive Diseases are engaged in studies that are continuing to blur these boundaries while also improving the diagnostic and therapeutic capability of endoscopy.

Dr. V. Raman Muthusamy, medical director of endoscopy for the UCLA Health System, has extensively studied a combination of resection and ablation techniques to treat Barrett’s esophagus patients, both as a strategy to prevent the development of cancer and for treating early esophageal cancers to avoid the need for surgery. Dr. Muthusamy, who helped to pioneer the use of radiofrequency ablation to burn off the dysplasia in Barrett’s patients, recently developed new quality metrics for these techniques, called endoscopic eradication therapy, with two colleagues. The American Society of Gastrointestinal Endoscopy and American College of Gastroenterology recently endorsed these metrics, which can be used to guide and assess endoscopists performing these procedures. Barrett’s esophagus is a complication of chronic reflux in which the lining of the esophagus begins to take on the appearance and characteristics of the lining of the stomach and small intestine, putting patients at a significantly higher risk of developing esophageal cancer. The ability to perform endoscopic eradication techniques that are far less invasive than surgery makes treating dysplastic Barrett’s esophagus — and thus reducing the risk of progression to cancer — a much more appealing option, Dr. Muthusamy notes.

Dr. Muthusamy is also exploring better ways to getting tissue from endoscopic ultrasound — focusing not only on how to obtain tissue from areas that have proved inaccessible, but also how to obtain enough tissue from more accessible areas (such as the pancreas) to allow for theranostics, or being able to profile tumors to predict which drugs will be most effective. “Historically we say if you have cancer of a certain type you get this drug, and some people respond while others don’t,” Dr. Muthusamy says. “Part of moving toward more personalized medicine is the need to get enough of the tumor to actually run these tests, which requires more than you would get just for a diagnosis.” His group is now using new needles to acquire additional tissue for a host of cancers. This increased ability to extract tissue with endoscopic ultrasound is also being applied to obtain liver biopsies during endoscopy.

Another member of the team, Dr. Alireza Sedarat, is utilizing and developing new resection techniques. In the past, endoscopists have removed only small lesions, but increasingly they have adopted approaches to remove larger cancers or precancerous lesions. After conducting animal studies, Dr. Sedarat is beginning to perform a technique known as endoscopic submucosal dissection (ESD) in patients, which allows for the resection of larger lesions than current endoscopic mucosal resection techniques. He is also performing peroral endoscopic myotomy (POEM) as an alternative to surgery for esophageal motility disorders, including achalasia — a condition of the esophagus in which the muscle is chronically contracted, making it difficult to swallow. “This is probably the most revolutionary endoscopic advance of the last 10-15 years, because traditionally the technique has been to open up the chest or go through the abdomen and cut the muscle of the lower esophagus,” says Dr. Muthusamy. Dr. Sedarat is currently the only interventional endoscopist in Los Angeles County offering the procedure.

Dr. Stephen Kim is conducting translational research to advance the treatment of pancreatic cysts. He has been collecting fluid from patients being treated for the cysts in an effort to develop better ways of characterizing them. By the age of 70, between 10 and 25 percent of patients are found to have a pancreatic cyst when they undergo radiologic testing. “Most of them don’t progress to cancer, but we have imperfect criteria for determining which ones do and which don’t,” Dr. Muthusamy notes. If Dr. Kim is successful, it will potentially pave the way for earlier intervention in patients whose cysts are determined to be problematic with less need to conduct costly monitoring of patients whose cysts are determined to be benign.

Both Dr. Kim and Dr. Muthusamy are developing strategies to ensure that duodenoscopes are kept as safe as possible in light of superbug outbreaks at hospitals. And Dr. Muthusamy is also exploring ways to improve the efficiency of endoscopic healthcare through better practice management to decrease delays and the costs associated with them.

“As our tools get better and better, endoscopic surgery and laparoscopic surgery are melding,” Dr. Muthusamy says. “We’re continually working to improve on the things we do, but also to expand into new areas that were typically surgical — in the endoscopic eradication therapy that I do for Barrett’s, for example, patients I see in the endoscopy unit all would have gone to surgery 10 years ago, and now almost none of them do. And as we blend the lines between surgery and endoscopy with regards to therapy, we are also working to get better at our diagnostic capabilities with endoscopes.”