Therapeutic endoscopy
Therapeutic endoscopy
Therapeutic endoscopy is the medical term for an endoscopic procedure during which treatment is carried out via the endoscope. This contrasts with diagnostic endoscopy, where the aim of the procedure is purely to visualize a part of the gastrointestinal, respiratory or urinary tract in order to aid diagnosis. In practice, a procedure which starts as a diagnostic endoscopy may become a therapeutic endoscopy depending on the findings, such as in cases of upper gastrointestinal bleeding, or the finding of polyps during colonoscopy.
A number of different techniques have been developed to allow treatment to be carried out endoscopically, to treat disorders such as bleeding, strictures and polyps.
Types of endoscopic therapy:
Endoscopic haemostasis
Injection sclerotherapy
Dilatation
Polypectomy
Variceal banding
Stenting
Percutaneous endoscopic gastrostomy
Foreign body removal
Endoscopic haemostasis:
Endoscopic injection of bleeding peptic ulcers with adrenaline has been practised since the 1970s.
Injection sclerotherapy:
Injection sclerotherapy has been used to treat esophageal varices since the 1960s.A sheathed needle is passed through a channel in the endoscope, unsheathed and pushed into a varix. A sclerosing agent, such as ethanolamine or absolute alcohol, is then injected into the varix to cause scarring and constriction of the varix with the aim of obliterating the varix (or varices). This technique has now largely been superseded by variceal band ligation.
Sclerotherapy has also been used in the treatment of gastric varices since the late 1980s. In this case Histoacryl glue (cyanoacrylate) is commonly used as the sclerosant. This technique is favoured over band ligation because the position of the varices in the stomach, most often in the gastric fundus, makes the placing of bands very difficult.
Dilatation:
Dilatation of benign esophageal strictures using semi-rigid bougies existed long before the advent of flexible endoscopes. Since that time oesophageal dilatation has been carried out using either bougies or endoscopic balloons, and can be used to treat benign oesophageal strictures and achalasia.
Initially, bougies were used to dilate benign strictures of the oesophagus. These could be passed alongside the endoscope, allowing visualisation of the bougie passing through the stricture, but the technique of passing a guidewire through the stricture endoscopically, then removing the endoscope and passing the bougie over the guidewire was more commonly used.
More recently, balloon dilatation of the oesophageal strictures has become more common. It is thought that this technique carries a lower complication rate than the use of bougies, and since endoscopy balloons are single use items there are no concerns about equipment sterilization. In addition to oesophageal dilatation, endoscopic balloons can also be used to dilate pyloric strictures.
Polypectomy:
Endoscopic polypectomy has been carried out since the early 1970s by both endoscopic snare removal and fulguration of polyps with hot biopsy forceps.
Variceal banding:
Oesophageal varices have been treated by band ligation since the late 1980s.
Non variceal indications include bleeding peptic ulcers. Banding allows clamping of bleeding vessels and achieves mechanical sealing without affecting the ulcers depth or size. These bands dislodge spontaneously and pass through the gastrointestinal tract safely within 3 weeks.
Stenting:
Expandable mesh stents can be deployed in the oesophagus at endoscopy, primarily in patients with inoperable oesophageal cancer which is causing dysphagia.Plastic stents can also be used to relieve obstruction of the Common bile duct at ERCP
Percutaneous endoscopic gastrostomy:
A method for inserting a feeding gastrostomy tube without the need for surgery was first described in 1980.This endoscopic technique is of particular use as many patients who require feeding tubes (such as after patients with swallowing difficulties after a stroke) are at high risk for complications from anesthesia and surgery, the endoscopic technique usually requires mild sedation only.
Foreign body removal:
Foreign bodies commonly impact in the lower oesophagus, and removal of these by pushing them into the stomach has been practised since the middle Ages. Foreign body retrieval, using forceps and magnets, has been practised since the time of rigid oesophagoscopy and bronchoscopy.