Medizinische Klinik C, Klinikum Ludwigshafen gGmbHGastroenterologie, Hepatologie, Diabetologie,

Gastroenterologische Onkologie

„KEY NOTE LECTURE“FUTURE OF ENDOSCOPY IN

GASTROENTEROLOGYJ.F. Riemann

L. Helmstädter

Falk-SymposiumFuture Perspectives in

Gastroenterology

Dresden, 11th-12th October 2007

Medical Department C, Klinikum Ludwigshafen, GermanyGastroenterology, Hepatology, Diabetes Care,

Gastrointestinal Oncology

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ENDOSCOPY

FUTURE PERSPECTIVES IN ENDOSCOPY

Quality Research

Technology

Prevention Interventions

Interdisciplinarity

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Diagnostics TherapyCombination1970

2007

HISTORY

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DIAGNOSTIC IMAGING

Structural Enhancement

High Definition Television (HDTV)

Chromoendoscopy (NBI, FICE, i-scan)

Adaptive IHb Color Enhancement

Autoflourescence-Imaging

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Structure EnhancementHDTV

(High Definition TV)

NBI(Narrow Band Imaging)

FICE(Fuji Intelligent Color

Enhancement)

DIAGNOSTIC IMAGING

Konventionell

NBI-Filter

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Adaptive IHb (Index of Hb)Color Enhancement

Colour Enhancement after calculation of hemoglobin concentration and comparison with

a reference index

Courtesy of R. Tamm, Olympus

DIAGNOSTIC IMAGING

AF CCD

Std CCDfor white light

endoscopy

LightGuide

LightGuide

biopsy

Autoflourescence-Imaging

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DIAGNOSTIC IMAGING

RED FLAG TECHNIQUESclear signal in the

presence of suspected lesions

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HISTORY OFSMALL BOWEL DIAGNOSTICS

push enteroscopyBenz et al., DMW 1997

In the 90s

use of transnasal sonde typeenteroscopesTada et al., Endoscopy 1986

intraoperative enteroscopyBosseckert et al., Endoscopy 1981

In the 80s

first use of endoscopes in small bowelClassen et al., DMW 1972

In the 70s

20th Century

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HISTORY OFSMALL BOWEL DIAGNOSTICS

21st Centurycapsule endoscopy (PillCam)Iddan et al., Nature 2000

2000

double balloon enteroscopyYamamoto et al., Gastrointest Endosc 2001May, Ell et al., Endoscopy 2003

2001

Olympus capsule (EndoCapsule)Hartmann et al., Endoscopy, accepted forpublication

2005

single balloon enteroscopyHartmann et al., Endoscopy, accepted forpublication

2007

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HISTORY OFSMALL BOWEL DIAGNOSTICS

notable simplification and improvement of proceduresexamination of the complete small bowelpossiblehigh diagnostic accuracytherapy in the hole small bowel possiblebecomes standard in all centers

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DIAGNOSTIC IMAGINGSmall Caliber Endoscopes

SpyGlass-SystemSingle-operator system

Four-way steering capability

Independent irrigationchannels

Diagnostic and therapeuticcapabilities

Disposable and multi-usecomponents

Courtesy of W. Weber, Boston Scientific

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FUTURE PERSPECTIVESPrevention

Incidence of CRC is increasingScreening-colonoscopy stagnates despitegood resultsShift in stages of CRCAcceptance is moderateImproved devices, new techniques

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Reasons for non-attendance of screening

no knowledge, no information 73%lack of interest, indecision 63%no time 62%fear of cancer 57%feeling healthy 43%no address / invitation 43%fear of examination procedure 39%mistrust in medicine 27%

V. Beck, Studie Stiftung Lebensblicke/DKG 2007

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Colono-Sight-SystemShike et al., DDW 2004

Cathcam-SystemGuidewire Colonoscopy

Fritscher-Ravens, Swain et al., Endoscopy 2006

FUTURE PERSPECTIVES„Smooth“ Colonoscopy Systems

Invendo-SystemHydraulic disposable

colonoscopeRösch et al., DDW 2007

Courtesy of A. Fritscher-Ravens

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Self propelling

Self navigating

Insufflation of CO2

360° Omni-View

FUTURE PERSPECTIVESAer-O-Scope

Vucelic, Arber et al., Gastroenterology 2006

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FUTURE PERSPECTIVES Aer-O-Scope

Scope-View X-ray (Pig)

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FUTURE PERSPECTIVESNeoGuide

Computer-assisted Colonoscope(partially automatic endoscope)

64 controllable segments and infraredsensors

Prevention of looping, pain, complications

Eickhoff A., Hartmann D, Van Dam J., Riemann JF; Am J Gastroenterol 2007

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FUTURE PERSPECTIVES NeoGuide

Simulation in an open model

conventional NeoGuide

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Ø11 mm

31 m

m

FUTURE PERSPECTIVESColon Capsule

Eliakim et al., Endoscopy 2006; Schoofs et al., Endoscopy 2006

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Pilot study capsule vs. colonoscopy at three centers:

Düsseldorf

Hamburg

Ludwigshafen (Management)

FUTURE PERSPECTIVESColon Capsule

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FUTURE PERSPECTIVESVirtual Colonoscopy

CT MRI

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FUTURE PERSPECTIVESVirtual Colonoscopy - CT

96.079.6Specificity93.888.7Sensitivity

≥10mm6-9mmAdenomatous Polyps

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LUVIK-Study

TANDEM CONCEPT

Pilot Study:

10084Sensitivity (Patients)10084Sensitivity (Polyps)

≥10mm6-9mm

Hartmann D et al., Radiology 2006

FUTURE PERSPECTIVESVirtual Colonoscopy - MRI

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FUTURE PERSPECTIVESInterventions

new Stents (e.g. oesophagus, biliary tract)

EMR ESD full-thickness resection1

endoscopic myotomy

interventional EUS

improved management of complications due to new suturing techniques

teleradiology (digital network-capable x-ray forbilio-pankreatic therapy) vs. open MRI

1Kaehler et al., Surg Endosc 2006

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FUTURE PERSPECTIVESStent Therapy

Oesophagus:SEMS loaded with 125Iodine-seeds in a rabbitt modelGuo et al., Eur J Radiol 2007

Enteral:partially covered double layer expandablenitinol stent in malignant gastoduodenalobstructionsKim et al., Gastrointest Endosc 2007

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Biliary tract:103Palladium radioactive stent in a dog modelHe et al., Hepatobiliary Pancreat Dis Int 2006

self-expandable helical biodegradable PLLA-stentMeng et al., J Mater Sci Mater Med 2006

SEMS with paclitaxel-eluting membrane (dog/human)Han et al., DDW 2007 / Lee et al., DDW 2007

FUTURE PERSPECTIVESStent Therapy

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FUTURE PERSPECTIVESESD

ERBE Hybrid-Knife

Courtesy of N. Yahagi

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Olympus R-Scope

Courtesy of R. Tamm, Olympus

FUTURE PERSPECTIVESESD

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FUTURE PERSPECTIVESEndoscopic Myotomy

submucosal endoscopic oesophageal myotomyPasricha et al.Endoscopy 2007

endoscopic pyloroplastyPark et al.Gastrointest Endosc 2007

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FUTURE PERSPECTIVESInterventional Endosonography

enteral anastomosesFritscher-Ravens et al.,

Gastrointest Endosc 2003

transgastriclymphadenectomy

Fritscher-Ravens et al.,Gastrointest Endosc 2006

transoesophageal intracardiacprocedures

Fritscher-Ravens et al., Endoscopy 2007

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g-Prox

double T-bar

Eagle-claw

FUTURE PERSPECTIVESEndoscopic Suturing Techniques

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FUTURE PERSPECTIVES Interdisciplinarity

Gastroenterologists & Surgeons

interdisciplinary Endoscopy

endopathology

NOTES

rendez-vous-techniquesnew dimension in

interdisciplinary tumor therapy

centers of competence

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Field of view: 500x500µmRange: 0-250µmLateral resolution: <1µm

Kiesslich et al., Gastroenterology 2003

FUTURE PERSPECTIVESEndomicroscopy

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predictive accuracy:

Barrett‘s epithelium 96,8%

Barrett‘s neoplasia 97,4%

Kiesslich, Gossner et al. Clin Gastroenterol Hepatol 2006

Helicobacter pylori

FUTURE PERSPECTIVESEndomicroscopy

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FUTURE PERSPECTIVESEndocytoscopy

Kumagai et al., Endoscopy 2004Squamous cell cancer

Normal squamousepithelium

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FUTURE PERSPECTIVES Interdisciplinarity

Endomicroscopy

Endocytoscopy

Molecular imaging

Endopathology

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FUTURE PERSPECTIVESN.O.T.E.S.

Natural Orifice Translumenal Endoscopic Surgery2004:

transgastric peritoneoscopy, appendectomy

2005:

transgastric tubal ligation, oophorectomy, hysterectomy, cholecystectomy, cholecystogastric anastomosis, gastrojejunostomy

2006:

transgastric distal pancreatectomy, splenectomy, lymphadenectomy

transcolonic cholecystectomy

2007:

transvaginal cholecystectomy, nephrectomy

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FUTURE PERSPECTIVESNOTES

Why NOTES-procedures:fast recovery (less pain, faster healing)

no hernia or infection of the abdominal wall

flexible access to intraabdominal areas, which are laparoscopically not or just difficult reachable (right flank of liver, underside of liver, retroperitoneum …)

no scares (attractive cosmetical result) ??

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FUTURE PERSPECTIVESNOTES

D-NOTES:e.g. Hochberger, Fuchs, Kähler, Meier, Feussner, Meining, Lamadé, Eickhoff

EURO-NOTES:e.g. Fockens, Bergström, Park, Fuchs, Lacy, Deviere, Swain

NOSCARe.g. Kalloo, Hawes, Rattner, Thomson, Swanström, Ponsky, Gostout

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FUTURE PERSPECTIVESNeoGuide NOTEScope

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FUTURE PERSPECTIVESNeoGuide NOTEScope

NeoGuide NOTEScope conventional endoscope

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FUTURE PERSPECTIVESNOTES

Multitasking PlatformDirect Drive System

C. Thompson, DDW 2007

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FUTURE PERSPECTIVESEndoscopic Research

molecular endoscopyprospective studiese.g. NBI-zoom-gastoscopy in patients with high risk for squamous cell cancer of the oesophagus

supply research (e.g. anti-reflux-studies)DFG Interest

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Endomicroscopy Immuno Histology

FUTURE PERSPECTIVESMolecular Endoscopy

Fluorescein labeledantibody (CD44)

Goetz et al., Endoscopy 2007

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FUTURE PERSPECTIVESQuality

standardized educationtraining centers (GATE, ENDOAkademie)improved simulatorsquality control (e.g. EPT-register)statistic of complications (transparency)

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ENDOSCOPY

FUTURE PERSPECTIVES IN ENDOSCOPY

Quality Research

Technology

Prevention Interventions

Interdisciplinarity

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ENDOSCOPY IN THE FUTURE

diagnostic precisionnew therapeutic dimensionsactive in researchinterdisciplinaryincreased quality-awareness

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to be continued ...