Challenges over 5 decades in Digestive endoscopy
Apr 13, 2005 - 7:25:38 PM

In the 2005 Lilly Lecture* at the Royal College of Physicians on Tuesday 12 April, Professor Peter Cotton outlines the development and progress of one of the greatest diagnostic and treatment tools of the twentieth century – the flexible fiberoptic endoscope. This invention changed irrevocably the practice of digestive medicine, but encountered resistance from the medical establishment throughout its early development.

Professor Peter Cotton is Professor of Medicine, and Director of the Digestive Disease Center, at the Medical University of South Carolina in Charleston. He was Consultant Physician at The Middlesex Hospital in London from 1973 to 1986.

Prior to the flexible endoscope, diagnostic tests for digestive disorders consisted mainly of barium meal, analyses of gastric acid, and fecal fat. Jejunal biopsy and liver biopsy were the only invasive diagnostic procedures. Endoscopy was limited to rigid proctoscopy and esophagoscopy. Many digestive complaints were attributed to stress. Medical treatments were restricted to diet, antacids, and bed rest.

Endoscopy evolved rapidly from the mid-60s onwards. New versions were developed which could reach the duodenum, and also collect biopsy specimens. Endoscopy of the colon was developed after some bizarre athletic adventures. One group gave patients a weighted string to swallow, and attached an endoscope to it after it exited the anus. They then pulled the endoscope up from the mouth…Long side-viewing instruments gave access to the bile duct and pancreas, a procedure called Endoscopic Retrograde Cholangio-Pancreatography (ERCP), an amazing breakthrough at the time

Once established in its diagnostic role, the next decade saw the development of the endoscope as a therapeutic tool, capable of managing esophageal obstruction, foreign bodies, acute gastrointestinal bleeding. ERCP with sphincterotomy allowed removal of bile duct stones, and placement of stents to relieve malignant obstructive jaundice. Yet while its uses were multiplying, its value was still being questioned by many in the medical establishment.

It took randomised controlled trials, repeated therapeutic success and the dogged persistence of committed endoscopists to ensure it became an accepted part of any digestive specialist’s armoury, an acceptance that came about by the mid-80s.

Endoscopy continues to evolve, as does the medical world around it. There are three main areas of current interest – new endoscopic technology, “competing” technology, and the increasing focus on quality and accountability.

Endoscopes are getting smaller (for screening), with new diagnostic adjuncts such as mucosal spraying, zoom scopes, image analysis and transmission(for expert opinions , teaching and research). Endoscopic ultrasound is being used to look beyond the mucosa. The easily swallowed endoscopy capsule was another breakthrough which captured the media and public’s attention. These developments are mirrored in field of therapeutics, where many surgical frontiers are being challenged.

The diagnostic role of endoscopy is changing as “competing” technologies such as CT, MRI, and PET scanning become more sophisticated. CT colonography, also known as virtual colonoscopy, can be accurate in the hands of well-trained specialists, and may well alter the future use of colonoscopy.

In recent years there has been an increasing focus on ensuring quality and accountability. Professor Cotton homes in on three aspects of this issue. The first is how to facilitate and speed the processes of training specialists, for instance endoscopists, and to provide training opportunities in breakthrough technologies for those who are formally beyond training. Endoscopists should be credentialed (validated) based on measurable cognitive and technical skills, a process that could be helped by computer simulation.

The second quality issue is providing the right services, which is sometimes difficult as medicine becomes more complex, and as physicians become more specialized. The phrase “for those who have only a hammer, everything looks like a nail” is pertinent in the world of super-specialized endoscopists and surgeons. The risk that patients get the wrong procedure (or are delayed in getting to the right service) can only be minimized by increasing the collaboration between specialties.

This is the vision behind the Digestive Disease Center concept which Professor Cotton initiated on moving to the Medical University of South Carolina in 1994. Gastroenterologists, surgeons and radiologists live and work in the same environment, with joint facilities and support staff to support the “patient-friendly” mission. This approach is being adopted increasingly in hospital environments, but there is considerable resistance from the heads of traditional academic departments (notably medicine and surgery), where much of the power (and money) remain. Eventually, there will be departments of “digestive medicine”.

Graduates from medical school with an interest in digestive disease will enter a period of training in “digestive science”, during which they will decide whether they wish to practice mainly as diagnosticians (consultative gastroenterology), whether they wish to follow a traditional surgical route, or a new track as a “therapeutic digestivist” embracing all of the techniques of minimally invasive surgery and flexible endoscopy.

The third quality issue is accountability. We should all know exactly what we are doing, compare that with relevant peers (benchmarking), and, most importantly, make those data available to any interested parties, whether they are patients, providers or payers. Professor Cotton supports the “report card” concept for endoscopists, which provide some basic data on endoscopic practice and outcomes. Collection of this data is increasingly easy as our environments become more electronic. “We should wear our data as badges of quality”.

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