Technical Advances in Gastroenterology (TAG ‘09) Symposium
I was fortunate to attend TAG ’09 which was held last month at Monash Medical Centre with the presence of two well respected international Experts in Endoscopy – Prof. Ralf Kiesslich (Germany) and Marc Giovannini (France). The Symposium aimed to showcase the most up-to-date advances in the field of Endoscopy / Endomicroscopy with a strong clinical, problem-based focus, and it certainly delivered. New techniques to examine the common bile duct, including Endoscopic Ultrasound, Choledochoscopy with SpyGlass for detection of ductal stones and strictures (malignant and non-malignant). These techniques allow biopsies of the suspicious lesions for definitive diagnosis which were not possible previously.
The Symposium also strongly focused on methods to detect early GI tract malignancies, particularly in high risk groups, such as high grade dysplastic Barrett’s oesophagus, sessile colonic polyps and early gastric cancers. Con-focal lenses which can now be fitted to high definition endoscopy systems allow superior visualization of the mucosal surfaces, particularly with dye contrast. I have no doubt early detection would lead improved patient outcomes, both in mortality and morbidity benefits.
Minimally invasive endoscopic techniques to resect early malignant lesions are also being employed and explored. Endoscopic Mucosal Resection (EMR) involves lifting the mucosa with saline based fluid to allow a snare to be applied around the entire lesion. Electro-thermo coagulation activation then removes the tissue safely without risks of perforation. These techniques are particularly useful for early oesophageal and gastric cancers.
Palliative stenting of obstructive lesions have also advanced a long way. There are bio-degradable stents available on the markets now. Although in early stages of development, the attraction of placing bio-degradable stents (eg. In oesophageal cancers) allows chemo-radiotherapy to be started without PEG tube insertion for feeding. Traditionally, post radiotherapy for Squamous Cells Carcinomas, the oesophageal stents tend to migrate as the tumour shrinks. Occasionally, the response is so great that the stent is no longer required. Removal of stents are not a risk free procedure and sometimes it may not be removable and the patient is left with the long term stent discomfort. Bio-degradable stents may be way for the future in this group of patients.
No doubt TAG 2010 will bring new ideas and as new technology develops, patients with GI tract would benefit from the minimally invasive endoscopy techniques.
- HAS IT ARRIVIED?
I attended an overview of developments of Virtual Colonoscopy at
the Digestive Diseases Week, San Diego in May.
Virtual Colonoscopy has potential major advantages in surveillance
and screening for polyps and cancer. What are the problems?
Present spiral CT or slower MR scanning can provide images of the
entire colon in 15 to 20 seconds, that is a single breath hold.
A Radiologist's assessment of the 2D slices or three-dimensional
images produced by computer manipulation may take between 30 and
60 minutes. Although automated fly throughs are being developed.
(a) Colon cleasing is still required and is a significant deterrent
to patient compliance. However, computer faecal deletion techniques
are being explored.
(b) Gaseous distension is necessary and uncomfortable for the patient.
Accuracy of results
For 6 - 9 mm polyps, sensitivity compared with present colonoscopy
is about half (50 to 80%) and for sessile polyps, which have a greater
malignant potential, is even worse.
In summary, in its present state of development, Virtual colonoscopy
is not an appropriate technique particularly for surveillance or
screening because of:
(a) Colon preparation and distension are still required limiting
(b) More expensive than colonoscopy due to
(1) equipment and (2) radiological interpretation.
Overall, real colonoscopy still remains the "gold standard"
and retains both its diagnostic and therapeutic application.
M.B.B.S. (Melb), F.R.C.S., (Ed), F.R.A.C.S. M.B. B.S. F.R.A.C.P.
SMALL BOWEL IMAGING
- THE GIVEN CAPSULE
Present endoscopic techniques of the bulk of the jejunum and ileum
are unsatisfactory and indirect methods are particularly inaccurate
in the diagnosis of GI bleeding.
Given imaging have developed a swallowed capsule containing a video
chip which over 8 hours can transmit an image to a recorder worn
by the patient during his/her daily activities.
Wonderful images are then later computer generated and can be directly
or automatically inspected and the rough site of the image capture
The tiny capsule costing about $6,000 US will revolutionise small
bowel imaging, but is unsuitable for the stomach or colon where
it can tumble without orientation (further information and images
obtainable from: www.givenimaging.com
M.B.B.S. (Melb), F.R.C.S., F.R.C.S. (Ed), F.R.A.C.S., M.B., B.S.,
In the past it has been suggested that a successful surgeon
needed to have grey hair to give seniority and wisdom and
haemorrhoids to give a look of constant anxiety the patients would
think was a natural concern for their well being.
The word "haemorrhoid" is derived from the Greek haemorrhoid
meaning flow of blood. The word "pile" comes from the
Latin pila meaning a ball or pill.
Evidence suggests that the anal cushions (haemorrhoids) provide
the final water type feel to the anal canal as the internal anal
sphincter does not close the anal canal on it's own. There is no
increasing evidence to suggest that haemorrhoids may be a world
wide phenomenon and dietary differences between developing countries
may not play such a significant role - rather, there are marked
variations in availability and acceptance of medical care.
Haemorrhoids increase in prevalence with age and there is an association
with hernia, geneta urinary prolapse and prostitism. Despite Buridtt's
dietary fibrehypothesis it is difficult to prove a relationship
between fibre and prevalence of haemorrhoids.
Positive family history is common and constipation and
straining are obvious causative factors. However, a significant
percentage of patients have normal bowel frequency. Interestingly,
haemorrhoids are not uncommon in vegetarians.
One English study has found the time spent in the toilet is significantly
longer for patients with haemorrhoids and may he related to sitting
with a relaxed perineum and unsupported anal cushions. Haemorrhoids
are divided into "first degree" - anal cushions that do
not descend below the dentate line on straining. By definition all
normal patients have first degree piles, but only haemorrhoidal
disease if they are symptomatic.
"Second degree piles' - anal cushions protrude below the dentate
"Third degree piles" - anal cushions descending to the
anal verge and remaining prolapsed.
"Fourth degree piles" - anal cushions are permanently
outside the anal verge.
Another classification which is more of clinical use as suggested
by British surgeons: -
1 .Occasional symptoms requiring reassurance only (after exclusion
of colorectal disease).
2. Bleeding with no prolapse. Treatment - Suppositories or
3 .Prolapse. Rubber band ligation and injection schlerotherapy may
4. Prolapse with large symptomatic external component.
Haemorrhoidectomy is probably required.
The vast majority of haemorrhoids may be treated without operative