November - 20208Endoscopy has undergone an incredible transformation over the past two decades. Previously, with the exception of endoscopic therapy for GI bleeding, removal of small to medium-sized polyps of the GI tract, and therapeutic ERCP, it was a primarily diagnostic technique that focused on imaging and tissue acquisition. Over the past twenty years, numerous advances have been made in the diagnostic and especially the therapeutic capabilities of these procedures. In my opinion, these advances primarily have centered on six major areas: (1) improved tissue resection techniques that facilitate the removal of early-stage tumors in one or more pieces; (2) submucosal or "third space" endoscopy techniques that have allowed for resection of subepithelial lesions and performance of myotomies to treat Zenker's diverticulum, achalasia and gastroparesis; (3) interventional endoscopic ultrasound procedures that have played important roles in treating benign and malignant conditions, especially involving the pancreas; (4) the development of bariatric endoscopy techniques to facilitate primary weight loss or treat weight regain after prior bariatric surgery; (5) artificial intelligence to detect and interpret lesions of the GI tract; and (6) improvements in reprocessing of endoscopes, especially duodenoscopes, along with the development of single-use endoscopes. Recently, advanced tissue resection techniques including endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) that have allowed the removal of large polyps, flat areas of focal dysplasia, and even early-stage cancers. ESD, in particular, allows for the removal of large lesions in one piece, so the assessment of margins and accurate tumor staging, if cancer is present, is possible. The information provided with these specimens is comparable to a surgically acquired specimen. These techniques have transformed our management of dysplastic Barrett's esophagus, early-stage esophageal and gastric cancers and markedly reduced the need for surgical resections for large colon polyps. Future advances should focus on improving the speed and ease at which ESD can be taught and performed as well as achieving adequate reimbursement for this technique. Submucosal or "third space" endoscopy involves accessing the third layer of the gastrointestinal wall by making an incision into the mucosa and creating a tunnel in the wall of the GI tract. The endoscope is advanced into this tunnel, and from this space, lesions in the wall of the GI tract such as gastrointestinal stromal tumors and neuro-endocrine tumors can be dissected and safely removed without the need for surgery. In addition, the muscle wall of the GI tract can be cut to treat diseases associated with increased muscle contractility such as Zenker's diverticula, achalasia, and gastroparesis. Once the lesion is removed, or the muscle has been cut, the endoscope is removed, and the mucosal incision is sealed with endoscopic clips, allowing the ability to perform what were previously surgical procedures entirely with an endoscope. Interventional endoscopy initially began with the injection of medications into the celiac plexus to relieve pain in the upper abdomen, primarily related to pancreatic cancer. However, the field has been transformed by the development of lumen-apposing metal stents (LAMS), which allow safe communication between two spaces/lumens to be created. This has led to markedly simplified and improved drainage of inflammatory pancreatic fluid collections (the FDA approved indication) as well as off-label, but widely utilized, applications. These include the drainage of infected gallbladders into the small bowel in patients who are poor candidates for surgery, internal drainage of obstructed biliary systems in patients with malignant obstruction and a prior TECHNOLOGY TRENDS IN GASTROINTESTINAL ENDOSCOPYV. Raman Muthusamy, MD, MAS, FACG, AGAF, FASGE, Medical Director of Endoscopy, UCLA Health SystemByCXO InsightsV. Raman Muthusamy
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