Surgical Endoscopy P. Sahle Griffith MBBS, MRCS, DM, FCCS - PowerPoint Presentation

1. Surgical EndoscopyP. Sahle Griffith MBBS, MRCS, DM, FCCSMedical Director, Surgical Solutions Inc., BarbadosMinimally Invasive Surgery Consultant, QEH, BarbadosAssociate Lecturer, UWI (Cave Hill)

2. DisclosuresNone

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4. Unfortunately there are battlelinesGastroenterologySurgery

5. A Little HistoryThe first endoscope was created in 1806 by Phillip Bozzini, a German-born urologistMaximilian Carl-Friedrich Nitze, another German urologist, produced the first usable cystoscope in 1877Mikulicz made the first gastroscope in 1880Basically flexible endoscopy evolved out of surgeons' need to overcome diagnostic and therapeutic challenges

6. Benefits of Endoscopy to the Surgeon

7. Current DemographicsSome European jurisdictions DO NOT ALLOW surgeons to do flexible endoscopy In North America Between 89%–97% of general surgeons reported endoscopy as a necessary skill for practiceEndoscopy is the fourth most common procedure performed by urban general surgeonscomprises 46% of all rural general surgery cases74 % of rural surgeons performed more than 50 flexible endoscopic procedures each year42 % of rural surgeons performing more than 200 flexible endoscopic procedures annually

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10. Questions of Quality Studies have reported general surgeons have higher rates of missed CRC, are more likely to require the assistance of anesthesiologists for colonoscopy Incorrectly perform surveillance colonoscopy at shorter intervals than current guidelines recommend.

11. So What is CompetencyA competent endoscopist must be able to:view the entirety of the colonassess suspicious lesions and obtain pathology specimens while maximizing patient safety and comfortCompetence has been defined as a greater than 90% success rate of cecal intubation in all cases (> 95% of screening colonoscopies)

12. The Question of TrainingLack of training time for General Surgery residentsIn Canada residents receive approximately 0.5–4 months of formal endoscopy education during the 2nd or 3rd year of residencyIn the Caribbean 0 dedicated hoursIn Barbados 3 month electives in 4th YearThe Canadian residents are expected to achieve the minimum threshold number of colonoscopies (50) and upper GI endoscopies (35), as per the requirements of the American Board of Surgery

13. In ContrastGastroenterology fellows receive 18 months of formal training in endoscopy Fellowship training programs require a minimum of 140 colonoscopies and130 upper GI endoscopies for minimal competence

14. So is it all a question of numbers?Wexner et al, evaluated 13,580 lower GI endoscopies performed by surgeons, and found that complications, ability to reach the caecum in >90% of cases, and total procedure times of <30 minutes were all achieved at an experience level of 50 cases, with modest improvement at volumes beyond that. Pediatric gastroenterologists have arrived at a similar number of 50 cases to define competency in colonoscopy for their traineesIn a study involving 14064 patients who had colonoscopy within three years prior to a diagnosis of a CRC, showed equivalent performance surgeons relative to gastroenterologists in regard to missed lesionsIn a study of specific metrics of performance in 5,237 colonoscopies performed by general surgeons, colorectal surgeons, and gastroenterologists found no differences among them

15. So why are we so good at it?Surgeons are intimately familiar with the anatomy of the GI tract through performing open and laparoscopic operationsTwo dimensional representation of a three dimensional structure from their extensive experience with laparoscopyThis could provide surgeons significant advantages over gastroenterologists in developing proficiency in endoscopyGastroenterologists lack this breadth of experience.

16. In my ExperienceAccredited Fellowship in Advanced Minimally Invasive Surgery -156 Flexible Endoscopies in that yearPerform approximately 140 Flexible Endoscopies per yearApproximately 40 laparoscopic Colectomies per year at 2 sites. Tattoo localisation of the tumours mandatory prior to laparoscopic resection

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18. In my ExperienceManagement of Surgical Complications - Slipped Gastric BandsDilation of Strictures Post Bariatric ProceduresDilation of Oesophageal StricturesPercutaneous Endoscopic GarstrectomyEndoscopic Management of In situ Colorectal Carcinoma

19. What should the future hold?Building the Peace - Cooperation with the GastroenterologistsFormalised training in flexible endoscopy during General Surgery resident training - Either a dedicated 3 month bloc, or longitudinal rotations over 3 yearsMore surgeons doing endoscopy Fundamentals of Endoscopic Surgery (FES)Credentialing

20. References:Skubleny D, Switzer N, Karmali S, de Gara C. Endoscopy services and training: a national survey of general surgeons. J Can Chir 2015; 58(5), 330-334.Unger SW, Satava RM, Scott JS. Resident education in surgical endoscopy. Am Surg 1992; 58: 643-6.Morgenthal CB, Richards WO et al. The role of the surgeon in the evolution of flexible endoscopy. Surg Endosc. 2007 Jun;21(6):838-53. Epub 2006 Dec 16.Hazey JW, Marks JM et all. Why fundamentals of endoscopic surgery (FES)? Surgical Endoscopy 2014; 28(3): 701–703.ABS Statement on GI Endoscopy. Feb. 24, 2011Wexner SD, Garbus JE, Singh JJ, et al; A prospective analysis of 13,580 colonoscopies. Surg Endosc 2001; 15:251-261. Hassall Eric, Training and Education Committee of the North American Society for Pediatric Gastroenterology, et al. Requirements for training to ensure competence of endoscopists performing invasive procedures in children. J of Pediatric Gastroenterology and Nutrition 1997; 24:345-347. Baxter NN, Sutradhar R, Forbes SS, et al. Analysis of administrative data finds endoscopist quality measures associated with postcolonoscopy colorectal cancer. Gastroenterology 2011; 140: 65-72. Mehran A, Jaffe P, Efron J, Vernava A, Liberman MA. Colonoscopy: Why are general surgeons being excluded?. Surg Endosc 2003; 17:1971-1973.

21. Thank You