Epoch making discovery of fibre optics based on the principle of total internal reflection by English physicist Herald Hopkins gave birth to flexible Gastrointestinal Endoscopy. Flexible gastrointestinal Endoscopy revolutionized practice of Gastroenterology. As aptly said by father of GI Endoscopy Peter B Cotton "Gastroenterologists were interested but impotent observers of pathology before the advent of fibre optic GI Endoscopy. Diagnoses were made by intuition, barium shadows and some basic blood tests. Endoscopes were rigid shiny metal tubes. With the widespread availability of endoscopes and smart endoscopic weapons practice of Gastroenterology became more scientific and effective.".
Therapeutic Endoscopy has made possible to remove the gallstones from the bile duct without having a scratch on the abdomen. Various therapeutic procedures such as sclerotherapy or banding of oesophageal varices, bleeding ulcers, dilatation of oesophageal strictures, balloon dilation of achalasia cardia, stenting of biliary, gastrointestinal pancreatic ductal stenosis, polypectomy, foreign body removal and various other procedures can be performed with endoscopy. Endoscopic treatment is much simpler as compared to surgery. The safety of various diagnostic and therapeutic procedures is well established. Complications in diagnostic endoscopic procedure are less than 1% while in therapeutic procedure is less than 10%. Though it is relatively easy to perform the endoscopic procedures technically training and continued experiences are necessary for optimal diagnostic accuracy and complex procedures like ERCP. Substantial investment of time for learning and constant practice is required to maintain adequate skills. Complications are most frequent in hands of inexperienced endoscopists. Results of interventional endoscopies are considerably influenced by varying operator skills, enthusiasms and discipline of the centre. As endoscopic procedures have less morbidity are taken up by many practitioners without proper evaluation of the benefit of the procedure. Outcome evaluation research must be done by endoscopists in scientific manner otherwise irrational use of endoscopic procedures will harm some of the patients who do not need these treatments and will bring a bad name to the specialty.
In this issue we have eminent gastrointestinal endoscopists from all parts of the country are contributing scientific information on various therapeutic endoscopic procedures. I hope this information generates adequate awareness about GI endoscopy in the clinicians.
- Deepak Amarapurkar
Sundeep J Punamiya
Interventional radiology (IR) began in the 1950s with manipulative procedures in the gastrointestinal tract, viz. hydrostatic reduction of intussusception. This probably was the first ever therapeutic procedure conducted by radiologists - a group that was until then, devoted to interpreting shadows on X-ray films. The rapid progress in medical technology has since then transformed the image of the radiologist from an armchair diagnostician to a dynamic and versatile clinical therapist. In fact, it was the eminent gastrointestinal radiologist, Alexander R Margulis, who coined the term "interventional diagnostic radiology" that defined the growing body of therapeutic procedures performed by the radiologist with the guidance of imaging techniques. IR has expanded rapidly, and now involved in the treatment of benign, malignant and post-operative conditions in virtually every organ system. The high success rate of interventional procedures, coupled with low morbidity and mortality, has made it a very attractive treatment option for GI and hepatobiliary disorders.
Significant developments in IR of the GI tract emerged in the early 1970s, with angiographic control of GI bleeding and non-operative removal of bile duct calculi. The late 70s and early 80s saw the emergence of percutaneous methods for draining obstructed biliary systems and intra-abdominal collections. This was followed by the revolutionary introduction of stents, which were deployed to relieve biliary, vascular and GI tract obstructions. The last decade saw innovative procedures such as transjugular intrahepatic portosystemic shunts (TIPS) and radiofrequency ablation of liver malignancies coming to the fore.
During this evolutionary process of IR, endoscopic therapy developed, grew and became the preferred mode of therapy of many conditions. Management of biliary diseases, GI strictures and variceal and non-variceal upper GI bleeding, once considered the exclusive preserve of IR and surgery, are now being easily carried out by endoscopic interventions. That does not mean that interventional radiological expertise is redundant. IR skills are invaluable in treating patients in whom endoscopy has failed or is not feasible. Also, IR remains the treatment of choice for many problems that cannot be managed as effectively and elegantly by any other means. These include, amongst others, inoperable liver tumours, intra abdominal abscesses, refractory ascites and hydrothorax, gut ischaemia, high-ductal biliary strictures and lower GI bleeding. The once competitive branches of therapeutic endoscopy and IR have now become complementary and work in close co-operation in treating GI disorders.
It gives me immense pleasure to be editor for this issue, incorporating reviews from national and international experts in IR and therapeutic endoscopy, and hope the readers benefit from their experience.
- Sundeep J Punamiya