Browsing by Author "Menke, Detlev"

In the past 10 years endoscopic diagnostics has benefited from technologies such as big chips, high-definition television (HDTV) and narrow band imaging (NBI). Video capsule endoscopy and double balloon enteroscopy have facilitated visualization of the entire small bowel. A number of studies on mucosal Barrett's and gastric cancers could prove that endoscopic mucosal resection (EMR) is oncologically equivalent to surgical resection when certain criteria are respected. However, EMR is less invasive and carries a substantially lower complication risk and mortality compared to surgery. Endoscopic submucosal dissection (ESD) facilitates en bloc resection with thorough histopathologic evaluation of the specimen, e. g. for mucosal lesions in the stomach and rectum. Endosonography (EUS) guided transgastric necrosectomy using a flexible gastroscope has set a milestone in the treatment of infected pancreatic necroses and has replaced open surgery in many centers. Natural orifice transluminal endoscopic surgery (NOTES) uses natural body openings as minimally invasive access to the abdomen and mediastinum. Interventional GI endoscopists and minimally invasive surgeons have profited from these innovations in micromechanics and microelectronics.

A 75-year-old multimorbid patient was referred to our department because of a suspected bile leak 4 days after a difficult "conversion" cholecystectomy. Multiple adhesions after prior right hemicolectomy and a deep discharge of the cystic duct into the common bile duct close to a diverticulum were found intraoperatively ERCP revealed an 8 mm linear defect at the bottom of a 4 x 2 cm duodenal diverticulum, most probably due to complex prior surgery. In accordance with the operating surgeons the defect was closed endoscopically using a "over-the-scope-clip" system (OTSC)

Endoscopic submucosal dissection (ESD) provides an "en bloc" specimen of even large laterally spreading mucosal tumors. 30 patients, with a single flat or elevated polyp over 2 cm in the rectum were treated by ESD. Results: 27 of 30 lesions could macroscopically be resected as "en bloc" specimen (90%). Relevant complications occurred in 2 patients (6.6%; 1 delayed perforation with subsequent vacuum sponge treatment, 1 delayed bleeding after 11 days). In 3 patients mild complications occurred (10%). All could be treated conservatively. Procedure related mortality was 0%. However, 1 patient with severe co-morbidity encountered a stroke and died 4days after the procedure. After a median follow-up period of 199days (9-1418days) one possible recurrence close to the scar in the rectum was detected and successfully resected (R0). ESD offers not only in Japan but also. in the Western World a reliable treatment option even for large laterally spreading rectal polyps. It seems also suitable for patients at elevated surgical risk. Due to the retrieval of an "en bloc" specimen and because of the low local recurrence rate ESD seems to be the oncologically by far preferrable procedure over standard "piecemeal" resection especially because of the high rate of early cancers in large rectal polyps.

Endoscopic submucosal dissection (ESD) in the esophagus is a technically challenging new clinical procedure. It offers a new perspective for the "en bloc" resection of early malignancies and severe dysplasia especially if multifocal in a Barrett's segment. In the following article we report on own first experiences with focus on technical aspects and give a short overview of the literature.

NOTES - International Status The clinical introduction of NOTES began only hesitantly, mostly due to negative experiences with the uncontrolled introduction of laparoscopic surgery in the early 1990s. To date, flexible endoscopic interventions within the abdomen have only been carried out in a limited number of cases due to a lack of proper instruments and poor knowledge about their use for parenchymal organs. However, over the past months, there has been remarkable progress and an exponential increase in clinical cases. In parallel, 'single port access surgery' has enabled access to the abdominal cavity with minimal trauma, minimal postoperative scars and the possibility of using long standard-laparoscopic instruments. Particularly in Germany, the number of transvaginal NOTES surgeries has increased considerably and will soon exceed 1,000. The present review reports experiences from the current literature as well as preliminary data which so far have only been presented at international congresses.

NOTES is an acronym for "Natural Orifice Transluminal Endoscopic Surgery" and represents endoscopic operations in sterile body cavities using the approach of natural orifices. In July 2005, a joint venture cooperation between the American Society for Gastrointestinal Endoscopy (ASGE) and the Society for American Gastrointestinal Endoscopic Surgeons (SAGES), was founded to coordinate research activities in NOTES. The so called NOSCAR group, which stands for Natural Orifice Surgery Consortium for Assessment and Research, described in a white paper, agreements about animal and clinical research leading to a stepwise introduction of NOTES techniques. In 2003 and 2004, the first documented human NOTES procedures were performed in India. In March 2007, first hybrid transvaginal cholecystectomies were reported in the USA and France. The conversion of laparoscopic or minimal-invasive surgical operations to NOTES interventions requires competition with low percentages of morbidity and a mortality of far less than 1%, as associated with laparoscopic appendectomy or cholecystectomy. Potential advantages of NOTES procedures is an improved cosmetic result, potential less postoperative analgesic requirement, and a potential reduction in immunological response. The introduction of new surgical techniques, promotes the impulsive development of new instruments. Multimorbid, old and overweight patients may benefit from a reduced invasiveness of NOTES procedures. NOTES is still in early developmental steps and its role is still undetermined. it is important to stepwise introduce NOTES, to prevent a too rapid development leading to devastating complications of routine procedures, which may question the development of NOTES. The education of endoscopic NOTES interventionalists may require the introduction of a novel educational curriculum, which may lead to the development of a hybrid physician with the background of an interventional endoscopic gastroenterologist and minimally-invasive surgeon.

Within the last years endoscopic submucosal dissection (ESD) has established its role for the "en bloc" resection of even large mucosal precancerous or early cancerous lesions. However, there is little literature concerning devices and settings used for successful ESD. In the following article we give an overview on technical requirements and report on our own experiences over the last years.

It is Currently unpredictable how the NOTES interventionalist of the future will look like and which "mother discipline" he will originate from. Will it be more important to be a specialist and virtuoso in conventional flexible therapeutic endoscopy or will count a prior experience in a patho-anatomical field. Will mean endoscopic surgery in the abdomen = visceral surgery, endoscopic nephrectomy urology, tubal ligation = gynacology or will a limited scientific background focussed oil the intervention be sufficient similar to the skills of an interventional radiologist? Clinically gastroenterologists currently concentrate on endoscopic sewing, closure of perforations and endoscopic anastomoses. Surgeons currently concentrate on rigid "single port access" surgery transvaginally or transumbelically ("E-NOTES") until new instruments will be created by industry. A new curriculum for the "endoscopic interventionalist" should be brought oil its way soon.