Gut and Liver 2010; 4(Suppl 4): S1-S8 The Society for Gastrointestinal Intervention. Are We, as an
Organization of Disparate Disciplines, Cooperative or Competitive?
Author Information
Richard A. Kozarek
Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA

Richard A. Kozarek
© The Korean Society of Gastroenterology, the Korean Society of Gastrointestinal Endoscopy, the Korean Society of Neurogastroenterology and Motility, Korean College of Helicobacter and Upper Gastrointestinal Research, Korean Association the Study of Intestinal Diseases, the Korean Association for the Study of the Liver, Korean Pancreatobiliary Association, and Korean Society of Gastrointestinal Cancer. All rights reserved.

Abstract
This is the Fourth Annual Meeting of the Society forGastrointestinal Intervention, a multi-disciplinary groupof practitioners committed to a minimally invasive approachto both the diagnosis and treatment of digestivedisorders. The key concepts are minimally invasiveand multi-disciplinary which can be construedas practicing in parallel with occasional lines of proceduraland clinical interaction or inter-disciplinary inwhich patients are acutely cared for by a team, withtreatments tailored to the patient and not the disciplinethat touches the patient first. In reality, manyof us exist in both worlds. Most universities and largeclinics are structured in departments along traditionaltraining lines. As such, Interventional Radiology ishoused in the Radiology Department, LaparoscopicSurgery (and potentially NOTES), as a component ofthe General Surgery Division, and Therapeutic Endoscopyusually resides within a gastroenterology structuralframework. These divisions have historically beenkept separate by multiple forces: salaries and budgetsusually reside in a larger division. As a group, theamount of practice devoted to GI disorders is variable(for instance, minimally invasive surgeons may approachthe adrenal glands or lung lesions in some institutionsand interventional radiologists often sampletissue in multiple areas outside the GI tract, and byvirtue of access to the vascular tree, can stent, embolize,or TPA almost any area of the body), as wellas inherent differences in our individual abilities to accessorgans. I have already mentioned that angiographiccapabilities allow the interventional radiologistaccess to virtually every GI organ and those capabilitiesallow therapeutic options for bleeding, tumorembolization, stenting of stenotic lesions, and formationof intravascular shunts. As such, there is verylimited interdisciplinary competition here although capsuleendoscopy as well as double and single balloonenteroscopy have improved the endoscopist’s diagnosticand potential therapeutic reach. However, manyof these diagnostic triumphs for obscure or massiveGI bleed are simply to tattoo lesions that require surgicalremoval by laparoscopic or traditional surgery.Cooperation. However, there are potential competitiveareas in the treatment of GI vascular lesions also.Whereas endoscopic band ligation has supplantedEVS, splenic devascularization, and most shuntingprocedures for patients with esophageal varices, endoscopictechniques have had less long-term successwith glue injection for gastric varices. Multiple randomized,prospective trials have suggested therapeutic primacyof TIPS with embolization of recalcitrant vesselsas an option or back-up. Despite this, therapeutic endoscopistshave learned valuable lesions from our IRcolleagues and studies are underway using endoscopicallyinjected coils in addition to cyanoacrylate inan attempt to improve acute and long-term bleedingcontrol. Nor is there any major competition in thetreatment of primary or metastatic liver tumors bychemoembolization, RF current, or other thermal modalities,although selected patients with single lesionsor multiple lesions isolated to a single lobe may bebetter handled surgically if there is curative intent.Finally, there is little IR, and progressively less, surgicalcompetition for the treatment of high-grade dysplasiaor superficial malignancies in the setting ofBarrett’s esophagus which are adequately treated inmost patients by mucosectomy, RF ablation, or cryotherapybut require direct mucosal visualization to directthis therapy. The same has proven true for manyyears for colorectal polyps, superficial gastric cancers,and ampullary adenomas that had historically all beentreated with major surgical resections. Still, there aremany patients with advanced lesions who are goodoperative candidates who should be approached withconventional or minimally invasive surgery with the intentof operative cure. Cooperative, not competitive.The potential for competition between disciplinescomes in mundane situations and clinical settings thathave historically been “owned” by a single discipline.On the one hand, placement of PEGS and PEJs, initiallydone endoscopically, can be done with equal facilityand occasional failure, by endoscopists and interventionalradiologists, reserving failed attempts forminimally invasive surgery. What resources are utilizedwith these three methods? Are there advantagesto defining the mucosa of the gut lumen in all, oreven a subset of patients? By way of contrast, acutecholecystectomy tubes in high surgical risk patientshave usually been the domain of the radiologist, althoughI described transcystic duct gallbladder decompressionendoscopically 2½ decades ago. With theadvent of new devices delivered under EUS control,the gallbladder will now be readily accessible endoscopically.What does this mean both for the acutely illpatient without a window to approach their gallbladderradiologically? Will this play a bit part and a cooperativetechnique to expand our therapeutic armamentariumor will it become competitive therapeutically notonly for IR but for minimally invasive surgeons? Thesame may be said for EUS’s ability to inject genes,caustics, or chemo-therapeutic agents into organs adjacentto the lumen. What is the role of TNFerade injectioninto unresectable pancreatic cancers and therole of absolute alcohol or Taxitol to treat cystic neoplasmsof the pancreas? The real issue of competitionor cooperation between the disciplines comeswhen treating patients with unresectable and obstructingGI neoplasms, from my perspective. The lattermay occur almost anywhere in the GI tract but, ofcourse, 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 andmany proximal colon lesions are better handled withan endoscopic approach because of loss of vectorforce and difficulty pushing a catheter through largediameter, acutely angulated lumens, all others are fairgame from my perspective. To my knowledge, althoughthere are studies demonstrating the superiorityof SEMS over open or laparoscopic bypass for malignantgastric outlet obstruction insofar as return of gutfunction, hospitalization time, and resource utilization,there are no studies demonstrating the superiority ofone discipline or another in the placement of SEMS.Nor have cost data emerged suggesting the superiorityof one technique over another from a coststandpoint. Unless or until we have such studies, thissuggests to me that institutional interest and expertiseshould play a major role in how these unfortunate patientshave continuity of their GI tract re-established.The situation is a bit more complex in pancreaticobiliarymalignancy. There are 2 prospective randomizedtrials (level 1 evidence) that suggest that patientswith proximal strictures (Bismuth II-IV) in conjunctionwith bile duct and gallbladder cancer, respectively,may be more successfully stented percutaneously andcertainly it is easier to deliver brachytherapy or PDTunder protocol to these patients who have indwellingexternal drains. In contrast, there are no data, positiveor negative, to suggest that PTBD is a preferabletreatment for distal biliary malignant obstruction, andin most parts of the world, the endoscopic approachhas supplanted the percutaneous one just as metalstents have replaced plastic prostheses to precluderecurrent bouts of stent dysfunction and need for additionalERCP. The question posed at the beginningof this syllabus contribution: Are we competitive or cooperative?The answer is obviously both but, hopefully,our choice of treatment should depend less onwho touches the patient first and more on skill setswithin an institution and what is the best treatment forthis particular individual. The importance of the SGI istechnical and informational cross-fertilization. If youruniversity or clinic will not allow blurring of trainingbarriers to put therapeutic endoscopists, minimally invasivesurgeons, and interventional radiologists togetheras a department or institute, you can neverthelesswork together as a team in the best interest of yourpatients.
Keywords: Therapeutic endoscopy; Interventional radiology; Minimally invasive surgery
Abstract
This is the Fourth Annual Meeting of the Society forGastrointestinal Intervention, a multi-disciplinary groupof practitioners committed to a minimally invasive approachto both the diagnosis and treatment of digestivedisorders. The key concepts are minimally invasiveand multi-disciplinary which can be construedas practicing in parallel with occasional lines of proceduraland clinical interaction or inter-disciplinary inwhich patients are acutely cared for by a team, withtreatments tailored to the patient and not the disciplinethat touches the patient first. In reality, manyof us exist in both worlds. Most universities and largeclinics are structured in departments along traditionaltraining lines. As such, Interventional Radiology ishoused in the Radiology Department, LaparoscopicSurgery (and potentially NOTES), as a component ofthe General Surgery Division, and Therapeutic Endoscopyusually resides within a gastroenterology structuralframework. These divisions have historically beenkept separate by multiple forces: salaries and budgetsusually reside in a larger division. As a group, theamount of practice devoted to GI disorders is variable(for instance, minimally invasive surgeons may approachthe adrenal glands or lung lesions in some institutionsand interventional radiologists often sampletissue in multiple areas outside the GI tract, and byvirtue of access to the vascular tree, can stent, embolize,or TPA almost any area of the body), as wellas inherent differences in our individual abilities to accessorgans. I have already mentioned that angiographiccapabilities allow the interventional radiologistaccess to virtually every GI organ and those capabilitiesallow therapeutic options for bleeding, tumorembolization, stenting of stenotic lesions, and formationof intravascular shunts. As such, there is verylimited interdisciplinary competition here although capsuleendoscopy as well as double and single balloonenteroscopy have improved the endoscopist’s diagnosticand potential therapeutic reach. However, manyof these diagnostic triumphs for obscure or massiveGI bleed are simply to tattoo lesions that require surgicalremoval by laparoscopic or traditional surgery.Cooperation. However, there are potential competitiveareas in the treatment of GI vascular lesions also.Whereas endoscopic band ligation has supplantedEVS, splenic devascularization, and most shuntingprocedures for patients with esophageal varices, endoscopictechniques have had less long-term successwith glue injection for gastric varices. Multiple randomized,prospective trials have suggested therapeutic primacyof TIPS with embolization of recalcitrant vesselsas an option or back-up. Despite this, therapeutic endoscopistshave learned valuable lesions from our IRcolleagues and studies are underway using endoscopicallyinjected coils in addition to cyanoacrylate inan attempt to improve acute and long-term bleedingcontrol. Nor is there any major competition in thetreatment of primary or metastatic liver tumors bychemoembolization, RF current, or other thermal modalities,although selected patients with single lesionsor multiple lesions isolated to a single lobe may bebetter handled surgically if there is curative intent.Finally, there is little IR, and progressively less, surgicalcompetition for the treatment of high-grade dysplasiaor superficial malignancies in the setting ofBarrett’s esophagus which are adequately treated inmost patients by mucosectomy, RF ablation, or cryotherapybut require direct mucosal visualization to directthis therapy. The same has proven true for manyyears for colorectal polyps, superficial gastric cancers,and ampullary adenomas that had historically all beentreated with major surgical resections. Still, there aremany patients with advanced lesions who are goodoperative candidates who should be approached withconventional or minimally invasive surgery with the intentof operative cure. Cooperative, not competitive.The potential for competition between disciplinescomes in mundane situations and clinical settings thathave historically been “owned” by a single discipline.On the one hand, placement of PEGS and PEJs, initiallydone endoscopically, can be done with equal facilityand occasional failure, by endoscopists and interventionalradiologists, reserving failed attempts forminimally invasive surgery. What resources are utilizedwith these three methods? Are there advantagesto defining the mucosa of the gut lumen in all, oreven a subset of patients? By way of contrast, acutecholecystectomy tubes in high surgical risk patientshave usually been the domain of the radiologist, althoughI described transcystic duct gallbladder decompressionendoscopically 2½ decades ago. With theadvent of new devices delivered under EUS control,the gallbladder will now be readily accessible endoscopically.What does this mean both for the acutely illpatient without a window to approach their gallbladderradiologically? Will this play a bit part and a cooperativetechnique to expand our therapeutic armamentariumor will it become competitive therapeutically notonly for IR but for minimally invasive surgeons? Thesame may be said for EUS’s ability to inject genes,caustics, or chemo-therapeutic agents into organs adjacentto the lumen. What is the role of TNFerade injectioninto unresectable pancreatic cancers and therole of absolute alcohol or Taxitol to treat cystic neoplasmsof the pancreas? The real issue of competitionor cooperation between the disciplines comeswhen treating patients with unresectable and obstructingGI neoplasms, from my perspective. The lattermay occur almost anywhere in the GI tract but, ofcourse, 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 andmany proximal colon lesions are better handled withan endoscopic approach because of loss of vectorforce and difficulty pushing a catheter through largediameter, acutely angulated lumens, all others are fairgame from my perspective. To my knowledge, althoughthere are studies demonstrating the superiorityof SEMS over open or laparoscopic bypass for malignantgastric outlet obstruction insofar as return of gutfunction, hospitalization time, and resource utilization,there are no studies demonstrating the superiority ofone discipline or another in the placement of SEMS.Nor have cost data emerged suggesting the superiorityof one technique over another from a coststandpoint. Unless or until we have such studies, thissuggests to me that institutional interest and expertiseshould play a major role in how these unfortunate patientshave continuity of their GI tract re-established.The situation is a bit more complex in pancreaticobiliarymalignancy. There are 2 prospective randomizedtrials (level 1 evidence) that suggest that patientswith proximal strictures (Bismuth II-IV) in conjunctionwith bile duct and gallbladder cancer, respectively,may be more successfully stented percutaneously andcertainly it is easier to deliver brachytherapy or PDTunder protocol to these patients who have indwellingexternal drains. In contrast, there are no data, positiveor negative, to suggest that PTBD is a preferabletreatment for distal biliary malignant obstruction, andin most parts of the world, the endoscopic approachhas supplanted the percutaneous one just as metalstents have replaced plastic prostheses to precluderecurrent bouts of stent dysfunction and need for additionalERCP. The question posed at the beginningof this syllabus contribution: Are we competitive or cooperative?The answer is obviously both but, hopefully,our choice of treatment should depend less onwho touches the patient first and more on skill setswithin an institution and what is the best treatment forthis particular individual. The importance of the SGI istechnical and informational cross-fertilization. If youruniversity or clinic will not allow blurring of trainingbarriers to put therapeutic endoscopists, minimally invasivesurgeons, and interventional radiologists togetheras a department or institute, you can neverthelesswork together as a team in the best interest of yourpatients.
Keywords: Therapeutic endoscopy; Interventional radiology; Minimally invasive surgery
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