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Evolution of surgery to endoscopy

Kalloo, Anthony N.

Current Opinion in Gastroenterology: September 2018 - Volume 34 - Issue 5 - p 281
doi: 10.1097/MOG.0000000000000467
ENDOSCOPY: Edited by Anthony N. Kalloo

Division of Gastroenterology & Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, USA

Correspondence to Anthony N. Kalloo, The Moses and Helen Golden Paulson Professor of Gastroenterology Director, Division of Gastroenterology & Hepatology, The Johns Hopkins Hospital, 600 N. Wolfe Street, Blalock 465, Baltimore, MD 21287, USA. Tel: +1 410 955 9697; fax: +1 410 614 7340; e-mail:,

‘Progress lies not in enhancing what is, but in advancing toward what will be’ Khalil Gibran

The last decade has seen an uptick of endoscopic procedures for digestive conditions which were once treated only surgically. This is exemplified in two excellent reviews in this edition of Current Opinion: Endoscopic Techniques for treating Gastroesophageal Reflux (pp. 288–294) and Endoscopic Techniques for Full Thickness Intestinal Biopsy (pp. 295–300). Both reviews highlight, in particular, the use of time-honored surgical principles to create robust endoscopic approaches to these diseases. This evolution is also happening with bariatric surgery which was recently reviewed in Current Opinion[1]. A further example is palliation of malignant intestinal or biliary obstruction. No longer do endoscopists need to place endoscopic stents for palliation, which are technically difficult and suffer from tumor overgrowth, but they are now able to perform endoscopic bypass as would previously be done surgically [2]. Myotomies for achalasia and other motility disorders are transitioning from surgical to endoscopic approaches [3].

Why is this happening now? Recent advances in technology have generated endoscopic tools to create surgical-like solutions. Transoral Incisionless Fundoplication mirroring laparoscopic surgical fundoplication and Endoscopic Sleeve Gastroplasty mimicking laparoscopic sleeve gastrectomy are expected to be durable while less invasive. Emerging long-term data are now supportive of this notion.

Although this forecasts good news for patients (less invasive procedures with quicker recovery) and healthcare systems (lower costs), it does create challenges for advanced endoscopic training. Training in advanced endoscopy now offers a bewildering array of opportunities for the incoming trainee. The basic menu of advanced endoscopy training has expanded from Endoscopic Retrograde Cholangiography (ERCP) and Endoscopic Ultrasound (EUS) to now include bariatric endoscopy, interventional EUS, endoscopic resection (including full thickness), submucosal endoscopy (POEM), and endoscopic antireflux procedures. These are exciting times for the endoscopic interventionalist and this field will continue to blossom in our quest to create minimally invasive solutions for our patients.

Also in this edition, the rapidly evolving techniques of cholangioscopy and pancreatoscopy are addressed (pp. 301–308 and pp. 309–315). The reader will be updated on recent advances as these technologies expand our armamentarium of diagnostic and therapeutic techniques. Finally, the ever controversial topic of Sphincter of Oddi Dysfunction (pp. 282–287) will be deliberated. Recent work in this area has addressed some unanswered questions guiding the practitioners to best practices.

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Financial support and sponsorship


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Conflicts of interest

I am a founding member and equity holder of Apollo Endosurgery.

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1. Kumbhari V, Hill C, Sullivan S. Bariatric endoscopy: state-of-the-art. Curr Opin Gastroenterol 2017; 33:358–365.
2. Chen YI, Khashab MA. Endoscopic approach to gastrointestinal bypass in malignant gastric outlet obstruction. Curr Opin Gastroenterol 2016; [Epub ahead of print].
3. Khashab MA, Benias PC, Swanstrom LL. Endoscopic myotomy for foregut motility disorders. Gastroenterology 2018; 154:1901–1910.
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