Creating the Future of (Endoluminal) GI Interventions

Abstract

Major innovation into how we pursue diagnosis and therapies for gastrointestinal (GI) diseases is urgently needed to seek better, less invasive, and less costly innovations in diagnostic and therapeutic interventions in the GI tract. Learning from prior paradigm shifts in cardiac and vascular we present here several initial steps we have undertaken to follow the endoluminal path, using advanced imaging methods, including endoscopy, and data management with avoidance of entry into a body cavity when possible. We will review the benefit and ease of incorporating routine fluoroscopy with endoscopy to improve safety and efficiency. We describe the development of "hybrid" procedure rooms for GI interventions and rationale for their use. We also emphasize the importance of collaborating with interventional radiologists, software engineers, and data specialists. We predict major improvement in outcomes in both diagnosis and treatment will follow.

Keywords: GI diseases; endoluminal surgery; fluoroscopy; health care costs; hybrid operating room.

Fig. 1

Use of a hybrid operating room (OR) in the treatment of a small bowel obstruction. Yellow arrow points to cone-beam computed tomography (CBCT, Siemens Artis, Malvern, PA) arm. White arrow 1: fluoroscopic image. White arrow 2: CBCT three-dimensional (3D) image. White arrow 3: colonoscopic image. Interventional radiologist on the left, endoscopic surgeon on the right.

Fig. 2

Cone-beam computed tomography (CBCT) in a hybrid operating room during the endoscopic treatment of a patient with small bowel obstruction. The C-arm of this equipment sweeps over an arc of 200 degrees (yellow double arrow), permitting CT-like images and the creation of three-dimensional (3D) and fusion images that are coupled with the preoperative CT scan. Note the colonoscope (orange arrow) has been inserted to point of pathology while obtaining CBCT images.

Fig. 3

( A ) Injection of water-soluble contrast through the colonoscope through the instrument channel in a patient 3 weeks postop abdominal surgery with distal small bowel obstruction. There is a “kink” in the small bowel that correlated to the preop CT scan. ( B ) Attempting to pass a guidewire past the kink led to—( C ) a sudden change in the anatomy (adhesion broke) and—( D ) the scope moved into dilated small bowel upstream of the former kinked area, leading to recovery of patient.

Fig. 4

Use of preoperative imaging planning permits consideration of a percutaneous entry point to treat an adhesive small bowel obstruction: ( A ) The coronal and axial computed tomography (CT) images show there is a loop of small intestine located superficially under the upper abdominal wall (coronal image: yellow arrow shows transition point). ( B ) Axial image CT: Yellow arrow highlights preop proposed entry point for “cut down” approach in the abdominal wall. ( C ) “Cut down” approach: The loop of the intestine 10–15 cm upstream of a small bowel obstruction may be targeted using advanced imaging and brought up to the skin level. The obstruction is identified in the hybrid operating room then dilated using guidewires and balloons through the “cut down” area. The entry area (yellow circle) is sutured closed under direct vision, and the patient has a very limited laparotomy as a result. The 18F red rubber tube was used to tighten a purse-string around the entry hole in the small bowel (yellow circle), in which a 0.035-inch guide is currently resting.

Fig. 5

Using balloon dilation to open up an adhesive small bowel obstruction under fluoroscopic guidance. ( A ) A “waist” is noted at the site of the presumed adhesive band (arrow) as the balloon dilator is inflated with contrast material. ( B ) Gentle slow balloon inflation eliminates the “waist,” presumably an adhesion. Usually, the waist “pops” open as the balloon straightens. Balloon dilation of an adhesive narrowing successfully accomplished using a common vascular balloon dilator used on the iliac arteries (Mustang 20 mm × 4 cm, Boston Scientific).

Fig. 6

Using advanced imaging methods to percutaneously access the small intestine for placement of a tube to relieve malignant obstruction. This is an image created “live” in the hybrid operating room (OR). ( A ) Three-dimensional (3D) image of contrast-filled small bowel is coupled with Needle Assist (GE Healthcare) to permit precise entry into the small bowel after the placement of T-fasteners (Saf-T-Pexy T-fasteners, Avanos, GA) to hold the bowel up against the surface of the abdominal wall. The small vertical lines show proposed points of entry of T-fasteners and then the feeding/bypass tube. ( B ) Fluoroscopic image of successful percutaneous placement of a long feeding tube through a malignant obstruction (small arrows), with sites of T-fasteners and percutaneous entry of feeding tube in the lower abdomen (large arrows). The puncture points through the skin, abdominal wall, and into the bowel were projected onto the fluoroscopic screen “live” in the hybrid OR (the colored vertical lines above) using the General Electric “needle guide” software.

Fig. 7

Use of “segmentation” to create a three-dimensional (3D) course of small intestine in a patient with complex fistula. ( A ) “Segmentation” of preoperative computed tomography (CT) scan images (green dotted lines) outlines the small intestine so that a 3D image may be created in the hybrid operating room (OR) (General Electric software). ( B ) Use of this imaging software (General Electric Cone Beam CT Discovery) in the hybrid OR permits creation of a 3D reconstruction of the intestine following segmentation. The “X” on the screen shows the site of the fistula present, and the image can be rotated to look at the fistula from multiple 3D angles. (The multiple white dots on the screen are metallic tacks placed in a previous ventral hernia operation.)