GI Endoscopy, who is better at it, and who should most of it?

[task]

Curious about the thinking out there.

It would seem that the lucrative nature of GI Endoscopy would make it a point of contention between Gen. Surgeons and GI docs -- who does it better, who should mostly be doing it, etc. But this probably varies from school to school and city to city.

Where I went to med school, the surgery program was stronger in terms of faculty and residents than the medicine program (though that is probably changing now with the downswing in apps to GS programs). But as a result, GS tended to be very dominant in doing endoscopy. The surgeons even have their own ERCP fellowship. As a result, something like 50% of GI endoscopy in the town where I went to school is done by surgeons.

However, where I am in training for Medicine is a top 5 program in IM and is much stronger than surgery, so GI endoscopy is pretty much under the auspices of GI -- not that the surgeons don't do their own in their Units and for colorectal cases, but the vast majority is done by GI.

As with any procedural field, numbers help build proficiency and would seem to make complications less likely. GI docs could argue that procedurally speaking, because they train in all facets of endoscopy, and only endoscopy, they should be the one's doing most of it on a daily basis. Theoretically, they should be better at passing the pylorus with greater speed and proficiency, or have a quicker time to cecum on c-scopes, as some examples.

Surgeons might argue that "I can open the abdomen, so why shouldn't I be just as good as putting a tube into the GI tract and moving it around, plus if there is a perforation, I can fix that too".

However, what is the rate of perforations for a given endoscopic procedure (including ERCP) that might require operative intervention? From what I've read, the % are pretty small. Most of it is waiting and abx.

It would seem that in private practice, many sugeons steer away from endoscopy not because they don't feel proficient at it, but because it would be biting the hand that feeds them (GI doc referrals). I would also think it would take away from OR time. But maybe there is a proficiency issue.

But many of my GI colleagues argue that operating on someone and using an endoscope involve a different set of skill sets, and that being good at one may not make you automatically good at the other. Wonder what the surgeons out there think of that?

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[pags]

I'm in Long Island, NY, and here, GI's scope and surgeons cut. There is little turf battle from what I gather. This shouldn't be an issue of who is better, but who "should" be doing the procedure. Obviously, in the end, the one who has the most practice, usually will develop the most skill. Most general surgeons I've known were too busy handling their own surgical workload to be playing with new fiber optic endoscopic equipment. There seems to be more turf battle between orthopods and neurosurgeons when it comes to spinal surgery. Maybe someone out there can argue that point.

 

[droliver]

Upper & lower endoscopy is an easy procedure to learn & you can become pretty proficient at it after a month or two. Most of the community general surgeons we work with do 10-15/week c-scopes. ERCP is more technically demanding and takes more to become proficient at it, & for most surgeons it is not time or cost-effective to do. Surgical endoscopy is a subspecialty fellowship which deals with learning ERCP skills & managing complex hepato-billiary dz.

a few observations:
- Gastroenterologists & Surgeons who do endoscopy are equally proficient at it. Again, it is not hard to do on most patients.

- "virtual colonoscopy" via CT scanning will probably replace a colonoscope for screening purposes in low-risk patients in the next decade and will really pose a number of painful financial issues for gastroenterology as field. Surgeons will be less affected as they do less.

- anti-reflux surgery will challenge/replace the chronic medical mgt. of GERD due to 1) statistically signifigant esophageal CA risk reduction will be demonstrated & 2) financial pressure => ie. it is much cheaper for society to have the up-front cost of surgery versus paying for expensive drugs every day for the rest of someone's life

- endoscopic anti-reflux techniques are being investigated. A number of devices came to market in the past for this but ended up killing a number of patients due to esophageal perforations. Newer devices will led to a lot of gastroenterologists (& surgeons to a lesser degree)attempting this & will initially lead to a great deal of early morbidity & mortality.

 

[task]

droliver

Some good points. However, unless there are newer anti-reflux surgical procedures coming down the pike, seems the the newer endoscopic procedures (endoscopic suturing, microsphere implantation into the lower esophagus, or RF energy) show much promise. I'm not as sure of the numbers as you probably are, but from what I understand, the #s of deaths from early devices in this field were a handful at most, and certainly not a deterrent to further innovation. And there was that JAMA article within the past year stating something like 70% of people s/p Nissen still went back on some form of medical regimen for their reflux.

With regards to virtual colonoscopy, at least from what I've heard from the GI people, they are all in favor of it. From what I understand, one does not get reimbursed for doing a c-scope unless one actually sees and does something during the procedure -- e.g. biopsy, polypectomy, etc. From the GI perspective, all the virtual colonscopy will do guarantee that every c-scope pays out. And for every virtual c-scope that sees something, someone still has to go in and get a sample of it.

 

[Voxel]

I doubt that virtual CT colonography will replace standard colonoscopy as of now, but 10 years from now who knows. We have to live that long.

Am J Gastroenterol 1999 Aug;94(8):2268-74
"Screening by colonoscopy remains more cost-effective even if the sensitivity and specificity of CT colonography both rise to 100%. For the two screening procedures to become similarly cost-effective, CT colonography needs to be associated with an initial compliance rate 15-20% better or procedural costs 54% less than colonoscopy.

Conclusion: To become cost-effective and be able to compete with colonoscopy in screening for colorectal cancer, CT or MR colonography would need be offered at a very low price or result in compliance rates much better than those associated with colonoscopy."

Having said that the use of multi-channel detectors in CT may increase the sensitivity/specificity of finding smaller lesions, but that will not matter if the public does not do a better job of getting this test. We have to convince the public that CT colonography (still put air into the rectum and need to be "cleaned out") is worth doing. Many people just do not want to have anything stuck in their rectum or drink unpleasant (gallons) liquids to clean out the colon. Personally it would be better than having to be sedated (sometimes partially) for standard colonoscopy. Also the risk of infection is probably smaller than standard colonoscopy. I think you may get more takers for virtual colonography but 15-20%? I'm not sure about that. As for cost, I think it is possible for a 54% reduction, just make sure it's not below the actual cost of doing the exam (both technical and professional) like mammography today.

As for reimbursement, Medicare/Most insurance pays for a "screening" colonoscopies even if the GI doc finds nothing. As far as I have heard GI docs are NOT in favor of CT colonography screening as it takes away lucrative income from them (it's their bread and butter procedure).

As for turf wars, well those are hard to avoid. Just look at interventional radiology, vascular surgery, and cardiology. There will be turf wars even between general surgeons and GI docs especially in crowded (metropolitan) areas.

 

[Voxel]

One other thought on GI procedures. For those of you who think ERCP will continue to be performed at the current rate by GI docs may be in for a surprise. MRCP (MRI virtual ERCP) (with 3T magnets) is being developed at a rapid clip and I think within 5 years may very well replace ERCP for everything but tissue biopsy (and even this may be done by IR docs) and stone removal. This will shift the GI docs focus to general upper and lower endoscopies. For many reasons, upper and lower GI series are performed with much less frequency (and to the delight of most radiologists). There is also increased interest in using endoscopic ultrasound for T staging of cancers which could also prove to be a boon for GI docs (or whoever performs endoscopies). So as with all things in life there are ebbs and flows. Technology changes landscapes.

 

[droliver]

Voxel,

Great points. MRCP will replace ERCP for most diagnostic imaging, while ERCP will be reserved for therapeutic interventions & ampullary biopsies. I still fell that virtual colonoscopy will ultimately prevail as costs plumet and due to customer (patient) preference of less invasive therapies.

TASK,

You correctly pointed out there are some innovative treatments being tried (endosuturing, radioabaltion,etc..). However, they all will ultimately be compared against a proven surgical tx. (ie. Nissen fundoplication) that is cheap, effective, and not very morbid when done laparoscopically. Also I'm not sure I want a gastroenterologist learning how to suture on my GE Junction

 

[Voxel]

About GERD. I think that the current proton pump inhibitors (and some of the H2 blockers) are great and in the future they will cost pennies to produce as they go generic. I think people will prefer those to the risks of any sorts of procedures. I believe that until the morbidity and mortality from non-invasive therapy (pills) is greater than the risk of surgery/endoscopy/anesthesia, I would NOT recommend any sort of invasive procedure.

 

[droliver]

Voxel,

important points not appreciated by most:

1. abscence of reflux symptoms does not equal abscence of reflux. Distal esophagitis has been shown to progress despite symtomatic refief w/ H2 blockers, PPI, antacids, etc.

2. there is a school of thought championed by Tom DeMeister (chair of surgery @ USC and who the Demeister Score for reflux w/ pH probes is named after) that the real carcinogenic player in reflux disease is bile reflux which has a basic pH and whose metaplastic potential is increased with chronic gastric pH suppression.

3. to date, only surgery has been shown to cause return to normal esophageal of early esophageal metaplasia


For these reasons (and the cost issues and lifetime dependence on medicine), there is an increasing voice for early surgery in the tx. for GERD.

 

[droliver]

Voxel,

important points not appreciated by most:

1. abscence of reflux symptoms does not equal abscence of reflux. Distal esophagitis has been shown to progress despite symtomatic refief w/ H2 blockers, PPI, antacids, etc.

2. there is a school of thought championed by Tom DeMeister (chair of surgery @ USC and who the Demeister Score for reflux w/ pH probes is named after) that the real carcinogenic player in reflux disease is bile reflux which has a basic pH and whose metaplastic potential is increased with chronic gastric pH suppression.

3. to date, only surgery has been shown to cause return to normal esophageal of early esophageal metaplasia


For these reasons (and the cost issues and lifetime dependence on medicine), there is an increasing voice for early surgery in the tx. for GERD.

 

[task]

For reflux disease, surgery may not always be the answer:

Of patients undergoing operations by highly experienced surgeons, 70-90% had good results that were maintained for 10 years after surgery. However, by 20 years after surgery, approximately one-third of operations may have failed. (Luostarinen M, Isolauri J, et al. "Fate of Nissen fundoplication after 20 years: A clinical, endoscopic, and functional analysis". Gut 34:1015-1020, 1993.

Comparing long-term outcomes from medical vs. surgical therapy for GERD, another study showed that after 11 years, a total of 92% of medical patients and 62% of surgical patients were still taking medicine for GERD. No difference was found in the grade of esophagitis, the treatment of esophageal stricture, subsequent antireflux procedures, or the incidence of esophageal cancer. However, the surgical group had statistically increased mortality. Spechler SJ, Lee E, et al. "Long-term outcome of medical and surgical therapies for gastroesophageal reflux disease". JAMA 285:2331-2338, 2001.

A recent, multicenter, prospective comparison of continuous treatment with omeprazole versus anti-reflux surgery showed nearly identical rates of remission for medical treatment and surgery during 5 years of follow-up. Lundell L, Miettinen, P, et al. "Continued (5-year) followup of a randomized clinical study comparing antifedlux surgery and omeprazole in gastroesophageal reflux disease". Journal of the American College of Surgeons 192:172-181, 2001.