This month’s On the Spot topic is endoscopy, just in time for the annual Society of American Gastrointestinal and Endoscopic Surgeons meeting! We debate transoral incisionless fundoplication, the trajectory of telerobotic endoscopic technologies, requirements for performing complex resection (endoscopic submucosal dissection and submucosal tunneling endoscopic resection) and third-space procedures (peroral endoscopic myotomy [POEM], peroral pyloromyotomy and Z-POEM [POEM for Zenker’s diverticulum]), and the race between endoscopic sleeve gastroplasty and laparoscopic Roux-en-Y gastric bypass.
Since endoscopy transcends most surgical specialties these days, it can be tricky to cover all the current debates. So, make sure to read not just the debates mentioned above, but also the “Gut Reaction”table that covers more topics such as the following: What is the most significant recent technique or device-driven advance in endoscopy? Bariatric endoscopies—should they have their own codes? Should endoscopy be a required core competency for accreditation of bariatric fellowships? Is the current requirement for minimum endoscopy numbers for general surgery residents enough? Read on to see what some of the experts think!
I would like to thank all contributors to this column for their hard work and time that make this a compelling column for all general surgeons and endoscopists. Feel free to email me at colleen@cmhadvisors.com with any ideas for debate. Thanks for reading!
—Colleen Hutchinson
Colleen Hutchinson is a medical communications consultant at CMH Media.
| E X P E R T P A N E L | |
|---|---|
 | Vice Chair, Innovation and Technology Division Chief, Foregut Surgery and Surgical Endoscopy Professor of Surgery Cleveland Clinic Lerner College of Medicine Cleveland |
 | Clinical Professor of Surgery, Rosalind Franklin University President and CEO, Chicago Institute of Advanced Surgery Chief of Metabolic Surgery, Advocate Aurora Illinois Masonic Hospital Chicago Disclosures: Consultant: Ethicon, Gore, Medtronic; educational fellowship grant: Gore. |
 | David L. Nahrwold Professor of Surgery Chief, Division of Minimally Invasive and Bariatric Surgery Director of Endoscopic Surgery Associate Program Director, Abdominal Wall Surgery Fellowship Department of Surgery, Penn State Milton S. Hershey Medical Center Hershey, Pa. Disclosures: Actuated Medical, Allergan, BD, Boston Scientific, Contamination Source Identification, Cook, Cranial Devices Inc., ERBE, Integra, Intuitive Surgical, Medtronic, Neptune Medical, Noah Medical, Springer, Steris, Surgimatix, Wolter Kluwer (UpToDate). |
 | Professor of Surgery Department of Digestive and Endocrine Surgery University of Strasbourg Director of Education, IHU-Strasbourg Vice-President, IRCAD Strasbourg, France |
 | Past President, Society of American Gastrointestinal and Endoscopic Surgeons, and the American Society of Gastrointestinal Endoscopy Past Chair, American Board of Surgery Professor Emeritus of Surgery Case Western Reserve University Cleveland |
 | Assistant Professor of Surgery Associate Program Director, General Surgery Residency University of Wisconsin–Madison Associate Program Director, General Surgery Residency University of Wisconsin–Madison |
1. Transoral incisionless fundoplication (TIF) will be a commonly performed procedure, employed by a high percentage of advanced endoscopists across a spectrum of practice types.
Dr. Ponsky: Agree. This procedure is not as durable or effective as fundoplication but provides effective therapy for many patients who are not surgical candidates or prefer not to undergo surgery.
Dr. Perretta: On the fence. Although I do believe there’s definitely a place for GERD endoluminal therapy, I’m not completely convinced by TIF, at least not yet. Being an upper GI surgeon, I am still uncomfortable with the current indications and results. As for GERD surgery, I believe that all anti-reflux operations should be performed by a practitioner who masters both endoscopy (rigid or flexible) and physiology.
Dr. Pauli: Disagree. TIF as currently practiced cannot overcome the structural anomalies that are seen in many patients who have reflux disease—in particular, hiatal hernias. In order for a truly incisionless fundoplication to see widespread acceptance, tools and techniques will need to be developed to allow for transluminal endoscopic closure of the diaphragm defects seen in many of these patients. Such techniques are in their infancy but will likely only be performed by a small percentage of advanced therapeutic endoscopists.
Dr. Lutfi: Agree—which is of note, since I was on the fence in our 2022 column on this topic!
Since then, more insurance plans have agreed to cover TIF, adding more lives to the pool of candidates. Additionally, the company has secured more funding (most recently $18 million to close 2022), which will help its marketing and expansion. Patients are looking for the “simplest” and least invasive option, often relating this perception to safety, which is not always true.
TIF will continue to grow until long-term data start showing increasingly reported recurrence—like the very many examples from the past. At that point, we may go back to favoring the good old Nissen!
Dr. Kroh: Disagree. The device and technique have improved significantly, and the data around the results are compelling—at least in the short term. However, there are a plethora of effective medical and surgical options that may limit broader use, as the indications for TIF remain fairly narrow from a mechanical and physiologic standpoint.
Dr. Shada: On the fence. There are two parts to this, with separate answers. Will TIF be more commonly performed? Probably so. This is driven by things such as user friendliness of the device (has improved somewhat since its invention nearly 20 years ago) and insurance coverage and reimbursement (Medicare now covers the procedure).
Will TIF be performed by a high percentage of advanced endoscopists across a spectrum of practice types? Not likely. While gastroenterologists and surgeons both do TIF, there is pretty strong evidence that TIF plus concurrent hiatal hernia repair has better outcomes than TIF alone. There is also a larger patient population who are candidates for TIF plus concurrent hiatal hernia repair compared with TIF alone. So, until we innovate to find a way to close the diaphragm endoscopically, this procedure will either need to be a joint venture between surgeon and gastroenterologist or be performed by surgeons with advanced endoscopy training.
2. Telerobotic endoscopic technologies will fundamentally alter how endoscopy is performed within the next five years.
Dr. Ponsky: Disagree. Although such technology may develop over the next decade, the preponderance of endoscopic procedures will be effectively performed with standard, less expensive methods.
Dr. Lutfi: Agree. While the superior ergonomic ability of robotics added more comfort in general surgery, it has failed to enable what’s enabled laparoscopically. On the contrary, I expect that the ergonomic advantages of robotic technologies will have a major impact on the field of endoscopy. Interventional endoscopy growth has been hindered by the obvious limitations of manipulating instruments and tools that have to go through the entire channel of the scope and, hence, are limited to open/close/rotate functions.
Robotic technology will allow the simultaneous use of multiple instruments with a great degree of freedom and articulation, thus achieving the currently nearly impossible task of dissection and suturing accurately, consistently and with a relatively short learning curve.
Provided the cost is reasonable, this technology will fundamentally and radically change endoscopy and its applications.
Dr. Shada: Disagree, mostly about the “five years” part of this statement. Therapeutic resectional endoscopic surgery is anxiously awaiting a stable operative platform that can employ surgical tenets like traction/countertraction and triangulation. I was so excited by studies demonstrating that robotic platforms allow novices to perform endoscopic submucosal dissection (ESD) faster than experts performing ESD with a traditional flexible endoscopy platform.
But it will take longer than five years to address both the technical and nontechnical aspects of telerobotic endoscopy, the technical aspects including creation of a stable operative platform in a mobile organ. The nontechnical aspects are perhaps even more challenging, including patient privacy, legal and ethical concerns about providing care remotely. The bright side is that we are making giant strides in the right direction. I hope I’m wrong about the time line, because once robotics and endoscopy merge, it’s going to be amazing to see where GI surgery goes.
Dr. Kroh: Agree. Yes! We are on the cusp of fundamental changes in how endoscopy care is delivered, and telerobotics will be central to this. New platforms and purpose-built robotics will enable complex procedures to be performed on the GI tract in more efficient ways with better precision.
Dr. Perretta: Agree. Robotic technologies will help standardize the practice of endoscopy, democratizing complex procedures such as ESD that are now performed only in centers of excellence (COE) by leaders in the field. Flexible robotics also will bring surgical doing and thinking into the lumen of the GI tract, pushing the limits of interventional endoscopy, enabling more complex procedures—procedures that we are incapable of performing with conventional scopes. Robots being information systems will also support navigation, diagnosis and decision making.
Dr. Pauli: Agree. Robotic endoscopes offer the prospect of performing complex surgical interventions through noninvasive means. They do this by recreating what we consider to be a traditional operative surgical platform: a stable device, multiple working channels, instruments capable of triangulating, and independent hands and eyes. These offer to be a great equalizer in the world of endoscopy. Surgeons who are comfortable with current surgical robotic techniques may feel empowered by their ability to navigate an endoscope robotically. Gastroenterologists who are comfortable with navigation may feel empowered by their new ability to cut and sew with robotically controlled tools. I suspect that we are at the dawn of an era of routine, organ-preserving, full-thickness endoscopic resections.
3. Complex resection procedures (ESD, submucosal tunneling endoscopic resection [STER]) and third-space procedures (POEM, peroral pyloromyotomy [POP], Z-POEM) should be performed by endoscopists with minimum annual volumes to ensure quality and consistency.
Dr. Shada: Agree. Like any advanced procedure, both initial training volumes and ongoing minimum volumes of endoscopic third-space surgery (annual, biennial or similar) are important to the delivery of quality care. Determining what those volumes are and enforcing said volumes is the real challenge. This is not unique to third-space endoscopy either; the same could be said for any procedural skill.
Dr. Kroh: On the fence. Volumes alone don’t predict quality. However, these procedures do require a specific technical skill set to result in good outcomes. The skills for these advanced techniques are somewhat interchangeable, and therefore, maybe a minimum volume for a single procedure isn’t the best metric. However, consistent performance of these interventions will improve efficiency and team performance, and possibly results.
Dr. Perretta: Agree. ESD, POEM and derived tunneling techniques are challenging and should be performed by experts who not only master the technical side of the procedure but also have a good understanding of the disease, including indications and contraindications, and are capable of managing potential complications.
Dr. Pauli: Agree. Unfortunately, I don’t know that anybody knows what the minimum annual volume is or what quality metrics we should be looking at for these procedures to deem a specific endoscopist capable of performing them. We have great data that some complex surgical interventions (e.g., esophagectomy) should be performed at a regional COE. It would be nice to have data supporting this concept for complex therapeutic endoscopic interventions of all sorts.
Dr. Lutfi: Agree. This is an easy one. Interventional endoscopy is much more complex, and therefore, is rapidly becoming a separate field from diagnostic or basic endoscopy. As the potential for these interventions increases, these increasingly complex procedures should be limited to highly specialized physicians and performed only in a COE. Like most COE, volume is one of the most essential criteria to credential centers and providers. The learning curve should be well defined for each of these procedures to fairly determine the minimum number needed to maintain certification.
Dr. Ponsky: Disagree. These procedures do not occur in large numbers, and may be performed intermittently with good results by well-trained individuals.
4. Endoscopic sleeve gastroplasty (ESG) will overtake laparoscopic Roux-en-Y gastric bypass (RYGB) as the second most commonly performed bariatric/metabolic procedure in the United States.
Dr. Lutfi: Strongly disagree. While incisionless procedures are always attractive to patients, and at times are perceived (often inaccurately) as safer, we cannot completely disregard and not disclose long-term data to patients—even those who may not ask for it. Gastric bypass is like fine wine! It has always stood the test of time.
Obesity is a humbling disease. Many devices came with lots of hope, only to leave with much disappointment and more patients to revise. That said, ESG is the beginning of a new and exciting era in approaching obesity. It serves as a bridge between medications and surgery. In the current platform, however, it is not yet set for prime time due to cumbersome suturing, tying and long learning curves. Now if I can bring you back to your earlier questions about telerobotic endoscopic technologies, I would say that ESG performed robotically will be a game changer, and the conversation then will be different—and more exciting!
Dr. Ponsky: Disagree. Although the endoscopic sleeve is proving effective, it will not be a substitute for RYGB, which remains the gold standard and will be necessary in a large number of patients to achieve significant weight loss.
Dr. Perretta: Agree! I believe the future of bariatrics is flexible! Not only is ESG safe and effective both on weight loss and comorbidities, but it doesn’t alter anatomy, can be repeated and can be easily converted to RYGB or sleeve gastrectomy. At our institution, we are performing it under sedation in selected patients and as an outpatient. I believe ESG should be the first step toward a more aggressive management of obesity in patients who failed lifestyle changes even before considering surgery. Combined with the new drugs, ESG could become the procedure of choice.
Dr. Pauli: On the fence. We have very good supporting data about the safety and efficacy of ESG in the management of obesity. Unfortunately, the majority of that data come from centers with clear excellence in bariatric endoscopy. What remains to be seen is what happens when ESG is released into the wild. What happens when the average surgeon or gastroenterologist begins to perform these procedures as part of his or her bariatric practice? Will the outcomes change? Will we see a rise in complications? Until we know a little more about this and until payors begin to reimburse for the procedure, I don’t think we are going to see a massive increase in ESG procedures.
Dr. Kroh: Agree. ESG will usher in a new era of endoluminal therapies for patients with obesity who are not currently receiving treatment. Positioned between medical and surgical therapies, ESG will be an important part of comprehensive obesity management that fits into the chronic and long-term interventions for obesity, the most important epidemic of our generation.
Dr. Shada: Disagree RYGB and ESG are both viable weight loss procedures, each with a different population that derives maximum benefit. Let me say up front that both ought to be performed within a bariatric COE to ensure optimal patient outcomes. Both have a learning curve and require specific skills. ESG in particular has a platform with a significant learning curve to do well, and until a more user-friendly platform is developed, the adoption of ESG will lag somewhat. Additionally, there are insurance coverage issues that limit performance of ESG more so than RYGB. However, the early results of ESG are encouraging, and if you ask me this question in another few years, my answer will likely be different.
| GUT REACTION | ||||
 Most significant recent technique or device-driven advance in endoscopy |  Bariatric endoscopies: Should they have their own codes? | Endoscopy: Should it be a required core competency for accreditation of bariatric fellowships? | Current requirement for minimum endoscopy numbers for general surgery residents: Is it enough? | |
|---|---|---|---|---|
| Rami E. Lutfi, MD, FACS, FASMBS, ABOM | Again, telerobotic endoscopic technologies | Only theoretically; watch out for decreasing reimbursement with assigned relative value units. | Yes for endoscopy. No (for now) for interventional/bariatric endoscopy | Yes, more than enough! Most of these residents will never scope! The non-rewarding pain of training uninterested residents going into non-GI specialties |
| Matthew Kroh, MD, FACS, FASMBS, FASGE | Robotics! | Yes, to represent the uniqueness and complexity of these procedures | Yes; important tool for all surgeons of the GI tract, especially bariatrics | It’s a start but not enough to later develop advanced skills without a fellowship. |
| Amber Shada, MD | Single-use endoscopes: game changer in multiple directions | Diagnostic endoscopy? No. Procedural endoscopy (i.e., ESG)? Yes. | All GI surgery fellowships should require some endoscopy exposure. | Yes, as a minimum for competency, alongside “Fundamentals of Endoscopic Surgery” |
| Jeffrey Ponsky, MD | The self-apposing metal stent | Yes | Yes | Yes |
| Silvana Perretta, MD | Endoluminal suturing, robotic endoscopy, new flexible endoscopy insufflation system, disposable endoscopes, lumen-apposing metal stents | Yes! | Yes, without any doubt | No! Competency-based assessments are needed. Look for quality, not quantity! |
| Eric M. Pauli, MD, FACS, FASGE | Endoluminal vacuum therapy | Diagnostic, no; therapeutic, yes | How can it not already be? | We should assess competency, not just case volume. |