|
Coming:
EUS-guided endoscopy
By Diana Swift
Orlando, FL—
Endoscopic technology must improve if it is to allow robust, one-time
intervention to control GI bleeding, said Christopher Gostout, MD.
“There’s been nothing much new in endoscopic therapy since
it was introduced in the 1970s, but I predict that in the next five
years, for example, EUS-guided therapy will be common,” said
Dr. Gostout, Associate Professor of Medicine and Director of Endoscopic
Research and Development, Division of Gastroenterology, Mayo Clinic,
Rochester, MN.
In a video presented at Digestive Disease Week, Dr. Gostout demonstrated
the use of new instruments, such as the Eagle Claw suturing device
(Olympus Apollo Group) that features two opposing talons. He showed
its application in suturing the splenic artery of a pig which was
isolated and implanted in the animal’s stomach. The procedure
simulated treatment of typical large-vessel bleeding in the human
upper GI tract.
He also showed the operation of a new three-pronged clipping device
developed by Wilson Cook, which allows for simultaneous irrigation,
and another prototype device which allows the placement of multiple
clips. Forceps are used to isolate and compress the point of bleeding
and visually control it before deploying a uniquely designed clip.
Dr. Gostout outlined several possible redesigns to the endoscope
that would facilitate therapeutic intervention.
“Instead of having jumbo therapeutic channels, maybe we should
have three or four small channels in one scope so we can apply multiple
tools more efficiently,” he said. “Current technology
allows us to miniaturize.”
With such a scope the gastroenterologist could locate bleeding sites,
apply injection therapy, and place a clip or ligature. “If
we need more channels, we can develop user-friendly overtubes that
don’t create a lot of discomfort for the patient and allow
us to have an extra channel that we could use for a grasping forceps.”
It might also be practical to mount endoscopes so gastroenterologists
could use both hands for multiple-device intervention. “We
spend most of our time with one hand holding the instrument, which
is a waste of 50 per cent of our therapeutic skills,” he said.
Another possibility is portable systems-backpacks or laptop models
that allow the gastroenterologist the mobility to go to any site.
Most significantly, with the increasing precision of imaging tools,
Dr. Gostout foresees the early advent of EUS-guided therapy. “I
predict that at one of these DDWs in the next five years, someone
will present embolization therapy that is EUS-directed.” Doppler
can identify a vessel, monitor blood flow as a vessel is being embolized,
and make sure the blood flow is going in the direction the embolic
material is released towards. “Smart therapy with pulsed Doppler
probes can also identify endpoints to make sure we don’t overtreat
and make bleeding worse. This is a sensible technology that is now
under study.”
A decade or so ago his group at the Mayo Clinic looked at the possibility
of using infrared imaging to visualize subsurface lesions but concluded
it was not practical. An abiding problem in endoscopic therapy is
the treatment of the isolated gastric varix, he noted. “We
are desperately in need of an acrylic glue here in the United States,”
he said.
|
