All About Advanced Surgical Endoscopy

In the early 20th century, rigid tubes were used for gastrointestinal examination, requiring patient contortion to align with the tubes to look inside the esophagus and colon.

Fiber optic technology developed midway through the 20th century allowed endoscopic tubes to become flexible.

Therapeutic endoscopy began with pinch biopsies to assess disease activity, then progressed to polypectomy using electrocautery snares to remove polyps that previously required surgical removal.

Endoscopic coagulation of bleeding ulcers can prevent the need for surgery.

Gallstones can be removed from the bile duct endoscopically by opening the bottom of the bile duct through the endoscope.

Balloon-assisted enteroscopy uses balloons on the outside of endoscopes that inflate and deflate to walk down the intestine farther than normal scopes, allowing visualization and treatment of lesions in the small bowel.

Video capsule endoscopy involves swallowing a pill-sized capsule with a flashing light that takes pictures frequently, recording to a hip-worn monitor to assess the small intestine for hidden bleeding sources.

ERCP allows access to the bile duct opening in the duodenum, enabling injection of dye to visualize problems, cutting of the opening to remove stones, and placement of plastic or metal stents for tumors.

Endoscopic ultrasound allows visualization beyond the intestinal wall to assess adjacent organs including the bile duct, pancreas, stomach wall, and vessels, enabling recognition and biopsy of tumors not visible by direct visualization.

POEM (per oral endoscopic myotomy) allows treatment of esophageal motility disorders by making a tiny incision in the inner esophageal wall, tunneling down through the esophagus, cutting the lower esophageal muscles, and closing the esophagus internally, avoiding abdominal surgery.

Endoscopic mucosal resection (EMR) can shave out tumors seen during endoscopy.

Endoscopic submucosal dissection (ESD) allows removal of flat, long, broad tumors by lifting tissue and shaving down to the next layer, providing better cancer or pre-cancer resection than EMR.

EMR and ESD have been proven safe and effective and avoid the need for open surgery.

Percutaneous endoscopic gastrostomy (PEG) was developed 40 years ago by Michael Gauer and Dr. Ponsky to place feeding tubes in patients who cannot eat due to neurological or oral problems, using endoscopic guidance for needle puncture without open surgery.

The PEG procedure was developed after observing bright transillumination through the abdomen of brain-damaged infants during endoscopy, realizing the stomach was in close contact with the abdominal wall and could be accessed with a needle.

All endoscopic procedures carry risks of bleeding, perforation, or infection.

Endoscopic pyloric myotomy can be performed as an outpatient procedure by opening the pyloric muscle in the intramural space, cutting the thick muscle, and clipping it closed, with patients going home the same day with improved gastric emptying.

Endoscopic pyloric myotomy requires only a liquid diet for 2 days before the procedure and one week afterward.

Zenker's diverticulum, which previously required major neck surgery, can now be treated through the mouth by making a small incision in the back of the throat, cutting the thick muscle, and clipping it closed, allowing same-day discharge.

Zenker's diverticulum repair requires a liquid diet for a couple of days before surgery and one week after.

Advanced endoscopic procedures are being performed as outpatients or with overnight stays in almost every case.

Every surgical procedure is being evaluated for less invasive, endoscopically guided approaches.

Robotics will play a future role in endoscopic surgery, including image-guided and robotically controlled surgery for more precise movements and better results.

Cleveland Clinic is conducting ongoing evaluation and improvement of endoscopic procedures, integrating new technology to improve results.