The society for gastrointestinal intervention. Are we, as an organization of disparate disciplines, cooperative or competitive?

Abstract

This is the Fourth Annual Meeting of the Society for Gastrointestinal Intervention, a multi-disciplinary group of practitioners committed to a minimally invasive approach to both the diagnosis and treatment of digestive disorders. The key concepts are minimally invasive and multi-disciplinary which can be construed as practicing in parallel with occasional lines of procedural and clinical interaction or inter-disciplinary in which patients are acutely cared for by a team, with treatments tailored to the patient and not the discipline that touches the patient first. In reality, many of us exist in both worlds. Most universities and large clinics are structured in departments along traditional training lines. As such, Interventional Radiology is housed in the Radiology Department, Laparoscopic Surgery (and potentially NOTES), as a component of the General Surgery Division, and Therapeutic Endoscopy usually resides within a gastroenterology structural framework. These divisions have historically been kept separate by multiple forces: salaries and budgets usually reside in a larger division. As a group, the amount of practice devoted to GI disorders is variable (for instance, minimally invasive surgeons may approach the adrenal glands or lung lesions in some institutions and interventional radiologists often sample tissue in multiple areas outside the GI tract, and by virtue of access to the vascular tree, can stent, embolize, or TPA almost any area of the body), as well as inherent differences in our individual abilities to access organs. I have already mentioned that angiographic capabilities allow the interventional radiologist access to virtually every GI organ and those capabilities allow therapeutic options for bleeding, tumor embolization, stenting of stenotic lesions, and formation of intravascular shunts. As such, there is very limited interdisciplinary competition here although capsule endoscopy as well as double and single balloon enteroscopy have improved the endoscopist's diagnostic and potential therapeutic reach. However, many of these diagnostic triumphs for obscure or massive GI bleed are simply to tattoo lesions that require surgical removal by laparoscopic or traditional surgery. Cooperation. However, there are potential competitive areas in the treatment of GI vascular lesions also. Whereas endoscopic band ligation has supplanted EVS, splenic devascularization, and most shunting procedures for patients with esophageal varices, endoscopic techniques have had less long-term success with glue injection for gastric varices. Multiple randomized, prospective trials have suggested therapeutic primacy of TIPS with embolization of recalcitrant vessels as an option or back-up. Despite this, therapeutic endoscopists have learned valuable lesions from our IR colleagues and studies are underway using endoscopically injected coils in addition to cyanoacrylate in an attempt to improve acute and long-term bleeding control. Nor is there any major competition in the treatment of primary or metastatic liver tumors by chemoembolization, RF current, or other thermal modalities, although selected patients with single lesions or multiple lesions isolated to a single lobe may be better handled surgically if there is curative intent. Finally, there is little IR, and progressively less, surgical competition for the treatment of high-grade dysplasia or superficial malignancies in the setting of Barrett's esophagus which are adequately treated in most patients by mucosectomy, RF ablation, or cryotherapy but require direct mucosal visualization to direct this therapy. The same has proven true for many years for colorectal polyps, superficial gastric cancers, and ampullary adenomas that had historically all been treated with major surgical resections. Still, there are many patients with advanced lesions who are good operative candidates who should be approached with conventional or minimally invasive surgery with the intent of operative cure. Cooperative, not competitive. The potential for competition between disciplines comes in mundane situations and clinical settings that have historically been "owned" by a single discipline. On the one hand, placement of PEGS and PEJs, initially done endoscopically, can be done with equal facility and occasional failure, by endoscopists and interventional radiologists, reserving failed attempts for minimally invasive surgery. What resources are utilized with these three methods? Are there advantages to defining the mucosa of the gut lumen in all, or even a subset of patients? By way of contrast, acute cholecystectomy tubes in high surgical risk patients have usually been the domain of the radiologist, although I described transcystic duct gallbladder decompression endoscopically 2½ decades ago. With the advent of new devices delivered under EUS control, the gallbladder will now be readily accessible endoscopically. What does this mean both for the acutely ill patient without a window to approach their gallbladder radiologically? Will this play a bit part and a cooperative technique to expand our therapeutic armamentarium or will it become competitive therapeutically not only for IR but for minimally invasive surgeons? The same may be said for EUS's ability to inject genes, caustics, or chemo-therapeutic agents into organs adjacent to the lumen. What is the role of TNFerade injection into unresectable pancreatic cancers and the role of absolute alcohol or Taxitol to treat cystic neoplasms of the pancreas? The real issue of competition or cooperation between the disciplines comes when treating patients with unresectable and obstructing GI neoplasms, from my perspective. The latter may occur almost anywhere in the GI tract but, of course, are more commonly noted proximally (esophagus, stomach, duodenum) and distally (left colon) as well as proximal and distal biliary obstructions. Recognizing that the occasional mid-small bowel and many proximal colon lesions are better handled with an endoscopic approach because of loss of vector force and difficulty pushing a catheter through large diameter, acutely angulated lumens, all others are fair game from my perspective. To my knowledge, although there are studies demonstrating the superiority of SEMS over open or laparoscopic bypass for malignant gastric outlet obstruction insofar as return of gut function, hospitalization time, and resource utilization, there are no studies demonstrating the superiority of one discipline or another in the placement of SEMS. Nor have cost data emerged suggesting the superiority of one technique over another from a cost standpoint. Unless or until we have such studies, this suggests to me that institutional interest and expertise should play a major role in how these unfortunate patients have continuity of their GI tract re-established. The situation is a bit more complex in pancreaticobiliary malignancy. There are 2 prospective randomized trials (level 1 evidence) that suggest that patients with proximal strictures (Bismuth II-IV) in conjunction with bile duct and gallbladder cancer, respectively, may be more successfully stented percutaneously and certainly it is easier to deliver brachytherapy or PDT under protocol to these patients who have indwelling external drains. In contrast, there are no data, positive or negative, to suggest that PTBD is a preferable treatment for distal biliary malignant obstruction, and in most parts of the world, the endoscopic approach has supplanted the percutaneous one just as metal stents have replaced plastic prostheses to preclude recurrent bouts of stent dysfunction and need for additional ERCP. The question posed at the beginning of this syllabus contribution: Are we competitive or cooperative? The answer is obviously both but, hopefully, our choice of treatment should depend less on who touches the patient first and more on skill sets within an institution and what is the best treatment for this particular individual. The importance of the SGI is technical and informational cross-fertilization. If your university or clinic will not allow blurring of training barriers to put therapeutic endoscopists, minimally invasive surgeons, and interventional radiologists together as a department or institute, you can nevertheless work together as a team in the best interest of your patients.

Keywords: Interventional radiology; Minimally invasive surgery; Therapeutic endoscopy.

Fig. 1

What makes minimally invasive therapies competitive?

Fig. 2

What brings minimally invasive therapeutic practitioners together?

Fig. 3

Postpolypectomy bleeding (A) treated with clip placement (B, C) and a subsequent endoloop snare (D, E).

Fig. 4

Portal-hypertension patient with TIPS × 2 (arrow) undergoing additional embolization for repeated gastric variceal hemorrhage (A). Despite the above intervention, recurrent variceal hemorrhage necessitated endoscopic cyanoacrylate-glue sclerosis of a residual bleeding varix (B).

Fig. 5

Abdominal plain film demonstrating a markedly dilated colon in a patient with an obstructing transverse colon malignancy that was treated with a self-expandable enteral metal stent (SEMS). Note the gastric SEMS (arrow) in this patient who initially presented with gastric outlet obstruction.

Fig. 6

Percutaneous transhepatic biliary drain (PTBD) demonstrating segmental filling of the right intrahepatic ducts (A) in the patient at 3 years post-Whipple for benign intraductal papillary mucinous neoplasm. (B) Endoscopic view of PTBD obtained with a double-balloon enteroscope. (C) Cholangiogram demonstrates a pus-filled, obstructed left system treated with multiple left and right intrahepatic stents (D) in a patient with sepsis and profound coagulopathy.

Fig. 7

Magnetic resonance imaging showing a walled-off pancreatic necrosis (A). Computed tomography demonstrates a high-grade biliary obstruction (B) treated with a biliary stent (arrow) and transduodenal pigtail-stent placement (C, D). Note subsequent percutaneous placement of an IR drain to allow irrigation and evacuation of necrotic debris (E). This combined therapy prevents the development of a pancreaticocutaneous fistula.