Flexible endoscopy continues to advance encompassing treatment of a variety of diseases traditionally managed surgically. This review describes and evaluates many of these new endoscopic approaches with an eye toward the future.
Gastroesophageal reflux disease is now treated with several endoscopic, non-operative techniques. A procedure using radiofrequency energy delivered by a peroral
catheter with small needles inserted into the wall of the esophagus causes
collagen deposition and ablates transient lower esophageal sphincter relaxation, both of which reduce reflux. With this treatment, >80% of patients will reduce or stop their medication for reflux. Trials involving new
injectable materials show promise with a 75-80% improvement in
heartburn-related quality-of-life scores and reduced medication use. Endoscopic
suture and stapling devices restore the antireflux barrier with
sutures that create a pleat or plication at the gastroesophageal junction. Early results indicated that 62-74% of patients had significant improvement. Long-term results are not available for any of these new techniques and there seems to be a drop off in effectiveness over time. Gastrointestinal
bleeding has been more effectively managed with the recent introduction of small clips and detachable
snares to control
bleeding vessels. Banding and
sclerotherapy for variceal
bleeding has all but eliminated urgent operation for that diagnosis. In the biliary-pancreas realm, endoscopic management of
pancreatic pseudocysts, stenting of pancreatic or biliary
strictures and fistulae have reduced operative indications in those disease processes. Pseudocyst drainage involves creation of a transenteric communication between the pseudocyst and the stomach or duodenum. Complete
cyst resolution without recurrence can be expected in 85% of patients. While endoscopic palliation of malignant biliary
strictures has been accepted for years, experience with endoscopic management of iatrogenic
strictures indicates that it may serve as an alternative option without surgery in many patients. Enteric stenting using metallic self-expanding
stents in the esophagus, duodenum, and colon allows alleviation of obstruction without surgery for palliantation and in the colon may relieve obstruction to avoid
colostomy prior to an elective resection. On the horizon stands the flexible endoscopic route to the abdominal cavity via the transgastric route and the promise of combined endoscopic-laparoscopic approaches to complex abdominal problems. General surgeons should rekindle their interest in flexible endoscopy or risk losing entire categories of disease to other specialties or to a small specialized group of endoscopic surgeons.