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Reducing Surgery and Its Associated Risks Through Advanced Interventional Endoscopy

Reducing Surgery and Its Associated Risks Through Advanced Interventional Endoscopy 150 150 Katie Brind'Amour, PhD, MS, CHES

Specially trained pediatric endoscopists can perform a range of diagnostic, interventional and therapeutic procedures for children, allowing them to avoid referral to adult endoscopists or even open surgery.

 

Muhammad Khan, MD, MPH, FASGE, the new director of interventional and diagnostic endoscopy at Nationwide Children’s Hospital, has big plans for the field of pediatric endoscopy. Among them are reducing the need for surgery — together with its obligatory pain and recovery time — and dramatically expanding the interventional capabilities of endoscopy.

After 10 years as a pediatric gastroenterologist specializing in endoscopy, Dr. Khan was frustrated that he had to keep sending his young patients to adult facilities for the most advanced procedures.

“Kids who need that level of endoscopic care usually end up having to get invasive surgery or endoscopy from an adult gastroenterologist, who is operating out of an adult institution and with adult tools, if they get timely care at all,” says Dr. Khan. “I was sick of seeing this over and over — I once had to send three patients in one week to the adult hospital — and I realized I needed to do something big.”

Dr. Khan applied for an advanced endoscopy fellowship and moved to Florida for a year of training on adult patients in the most advanced endoscopic procedures, including endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound (EUS) and peroral endoscopic myotomy (POEM). Now, his combination of education and experience in pediatric gastroenterology and endoscopy procedures makes him one of the only pediatric specialists in the country performing this full range of interventions.

“I want to take pediatric endoscopy to another level,” says Dr. Khan, who is overseeing construction of a customized interventional endoscopy suite at Nationwide Children’s. “The more we can do at a pediatric institution with pediatric gastroenterologists, the better it is for kids. We know kids the best, we know their diseases, their procedures and equipment, and we can take care of them before and after better than anyone else. Why wouldn’t you want a pediatric endoscopist treating them?”

What Conditions Can Benefit From Pediatric Endoscopy Approach?

The skills Dr. Khan learned span a wide range of pediatric conditions. One of his most common procedures includes robust polyp removal, even for complex hereditary polyps. This can be done via endoscopic mucosal resections or submucosal dissections, wherein Dr. Khan uses an electrically charged needle to peel lesions off of the wall of the colon and allow preservation of the GI tract. His tools can also cauterize GI bleeds and seal incisions.

ERCP is another complex procedure Dr. Khan and only a few dozen other pediatric gastroenterologists in the United States can perform. It allows the endoscopist to address problems in the ducts of pancreas, liver or gallbladder, such as stones or strictures. ERCP can be either diagnostic or interventional — or both at once — and utilizes a variety of tools and devices that can be passed through the endoscopy tube. It may also be combined with fluoroscopy for improved visualization.

EUS is a less commonly held skill among pediatric interventional endoscopists that allows extremely detailed imaging of the chest through the esophagus, or of the pancreas and other organs through the wall of the stomach and small intestine. It improves significantly upon external ultrasound and can offer insight that even computerized tomography (CT) scans can’t achieve, such as a tumor’s involvement with nearby blood vessels. The procedure can be combined with resection or biopsy to avoid invasive surgery or better inform oncologists or surgeons about the status of disease in the patient. Dr. Khan can also use the technique to place markers in a tumor to enable proton beam therapy.

Dr. Khan’s advanced training also makes something called third-space endoscopy possible. An example of this type of endoscopy is POEM, which can be used to treat achalasia or gastroparesis without surgery. It involves the use of a small cut in the inner lining of the esophagus or stomach, followed by the insertion of the scope between the inner and outer layer of tissue. The endoscopist can then make incisions in the muscle layer to relieve strictures.

Forging the Future of Pediatric Endoscopy

The technique of making tiny incisions to endoscopically access previously untouched areas in the abdominal cavity technically opens the door for a wide range of interventions without many of the risks and recovery time associated with traditional surgery. A notable example that sparked interest the field of natural orifice translucently endoscopic surgery (NOTES) involved the removal of a patient’s appendix through the mouth in India in 2005. Although this is far from current standard of care, Dr. Khan is adept at the endoscopic removal of polyps and masses from numerous internal organs, and he sees the potential benefit of expanding the range of interventions and resections performed endoscopically.

“We are opening a whole new world for pediatric endoscopy,” says Dr. Khan, who has collaborations underway with medical device companies to further improve tools for pediatric and infant use. “From going through the stomach wall to get a liver biopsy, to draining pancreatic cysts and placing stents from the cyst cavity to the stomach, we can now go beyond that inner layer of the GI tract to conduct procedures in kids that allow less or no pain and no external incisions. They can wake up with fewer complications, a shorter recovery time and a shorter hospital stay.”

Dr. Khan already has comparative research underway to examine outcomes for gastroparesis patients after POEM vs gastric neurostimulation. Other planned projects will shed light on whether endoscopic interventions should become standard of care for evaluation or treatment before advancing to abdominal surgery for certain conditions.

Dr. Khan is currently the only clinician in Columbus, Ohio, to offer third-space endoscopy options such as POEM, and one of only a few in the country who also perform ERCP and EUS. He accepts referrals for all pediatric endoscopic assessments and interventions, as well as personalized evaluations to see if surgery can be avoided for a wide range of biopsies and diagnoses.

About the author

Katherine (Katie) Brind’Amour is a freelance medical and health science writer based in Pennsylvania. She has written about nearly every therapeutic area for patients, doctors and the general public. Dr. Brind’Amour specializes in health literacy and patient education. She completed her BS and MS degrees in Biology at Arizona State University and her PhD in Health Services Management and Policy at The Ohio State University. She is a Certified Health Education Specialist and is interested in health promotion via health programs and the communication of medical information.

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