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The Interdisciplinary Endoscopic Department. How does it work? Is there a need for a new discipline: the visceral endoscopist, the interdisciplinary interventionist, the intraluminal surgeon or what else?
European Society for Surgical Endoscopy, 1st European Congress. VI Congresso Nazionale ISSE

Dear Colleagues,

Endoscopic surgery, including laparascopic intracavitary and flexible intraluminal endoscopy is rapidly replacing open surgery for lower postinterventional morbidity, reduced postoperative pain, shorter hospitalisation, faster return to normal activity, better cosmetic results and lower costs.

The endoscope enables in fact a better visualisation of the anatomy, but is handicapped by poorer tactile information from the field of operation.

From an electronical two-dimensional screen, the endoscopist has mentally to reconstruct the depth to three-dimensionality.In addition, specific hand-eye coordinations and fine motorial handling, quite different to open surgery, are required.

So it is evident, that an acquisition of these skills by an appropriate and effective training is essential for a really minimally invasive and atraumatic endoscopic surgery.  Nevertheless, there exist a world-wide lack of well structured, validated and generally accepted training programmes, specifically designed for training in surgical endoscopy. The proliferation of locally granted, low profiled training courses, based on different, if not contradictory interests and sectional modalities, is not surprising.

Today, as in the past, training is held in the endoscopy room at the patient present, predominantly according to the teacher-student model, historically based in the philosophy “first observe, than assist and finally operate”. For procedures of increasing complexity, the permanent presence of a tutor is mandatory. By this model, endoscopic skills can be learned with the time, but the reported learning curves are long.

To shorten learning curves and to reduce accidents on the curve, it is progressively accepted over the last few years, that training should be done outside the endoscopy room, using training simulators and animal models under supervised evaluation.

However, animal models and electronic devices are not widely in use for different reasons: costs, setting up, maintenance of training room and supervision.

Though the need of adequate training became evident and large series of different training programmes were designed, most training courses insufficiently documented or incompletely certified the achieved skills of their trainees. Therefore, the efficacy of training courses remains unproven and many questions, asserted by Campo, are still open:

Is a simple apprentice-tutor model sufficient to acquire the appropriate endoscopic skills?

What is the place of animal models in training?
Do they provide a more objective evaluation of the learning process?
What should be the intensity and duration of a training course to acquire the appropriate skills?

So, endoscopic surgical training and quality control are, without doubt, a very complex topic, having resulted in regrettable failures hitherto. But why?

To answer this question is difficult. It seems that the consideration of endoscopy as a mere tool – not as science – and increasingly used by many specialities, might be one reason of inacceptable poor training results.

This view seems to be valid, particularly for the part of digestive endoscopy.

One of the greatest barriers, that medical professions had to overcome since Hippocratic times was the barrier, built by our organism itself. As it got possible to pass these barriers by abdominal and thoracic incisions or drilling the skull, about 200 years ago, general, thoracic, vascular and orthopaedic surgeons, urologists, gynaecologists, otorhinolaryngologists and neurosurgeons were directly exposing the lesions, developing inside of cavities or hollow organs instead of using natural orifices and preformed pathways.

The presentation of the first flexible fiberscope, 50 years ago by Basil Hirschowitz revolutionized the endoscopic community throughout the world.

The rigid tubes for the oesophagus or rectosigmoid and Schindler’s semiflexible gastroscope were obsolete whithin a short time. For laparoscopy alone conventional instrument remained in use.

In the sixties, design, engineering and versatility of instruments evolved rapidly. Steering-controls in two, later in four directions, forward viewing, cold-light for illumination, flash-light for documentation, channels for biopsy, suction and insufflation were incorporated into even longer and slimmer instruments.

The seventies consolidated endoscopy of the upper and lower gastrointestinal tract as an established diagnostic tool, supported by refined visual observation, biopsy and histological proof. Barium studies of the upper and lower gastrointestinal tract were suddenly driven away by endoscopy, but for a certain period of time only.

Ultrasound, progress in radiology, CT and MRI began to regain much of the lost ground. The interaction between endoscopy, ultrasound and radiology produced an unprecedented diagnostic increase in many medical specialities.

In the eighties, the endoscope became a surgical instrument, as novel and daring interventions began to displace open surgery. In the oesophagus, endoscopists were dealing with fistulae, benign and malignant strictures, with bleeding varices by sclerotherapy or banding, significantly reducing the indication for portocaval shunts. Surgery for bleeding and rebleeding peptic ulcerations was preempted by endoscopic haemostasis.

In the colon, colonoscopy dominated the scene. Polypectomy was routinely performed and open surgery remained reserved for giant or broad based polyps and advanced malignant lesions. With experience gained and with acceptable low rate of complications, polypectomy became an outpatient procedure.

The pancreaticobiliary system was the undisputable area for endoscopy. The endoscopic definition of pancreaticobiliary concrements, strictures, cancer and patterns of chronic disease was the mainstream of that decade. Manometry and sphincterotomy followed immediately with subsequent positioning of catheters, baskets, balloons, dilatators and stents. In this field too, the endoscopist is in competition with radiologists, who, by percutaneous‑transhepatic access, aims at the same goal.

The nineties have seen the explosion of laparoscopic surgery upon one hand and the eradication of peptic ulcer disease by antibiotic therapy on the other. With the onset of MRT and virtual colonoscopy, the diagnostic era of intraluminal endoscopy is in decline.

In the current decade, intraluminal endoscopy takes a more and more aggressive development: mucosal resection and submucosal dissection for early malignancies and lesions with low risk of lymphatic metastases are routinely and successfully performed by our Japanese colleagues and friends.

In the Western World, natural orifice transluminal endoscopic surgery widens the endoscopic horizon. Its potential for human application – we will learn it today, here in this room within the next few hours. The actual developments of diagnostic endoscopy by vital staining, high definition, narrow-band imaging, coherence tomography, cytoscopy etc., without doubts require a highly specialized equipment and a long training for perfect application. This may support the idea to consider these techniques as the specific field and genuine tool of a single speciality. But the rapidly expanding profile of more and more invasive therapeutic endoscopic interventions requires special training programmes and a strict, complete and certified education.

The technique has to be supplied by science, that is the implementation of knowledge of anatomy in all its natural variations, knowledge of pathology, pathophysiology, epidemiology, semiotics, prognosis and outcome. Because all of this, intraluminal endoscopy can not longer be considered as a mere tool of one speciality. Intraluminal endoscopy achieves a higher score – it is a speciality for itself!

The identity of instruments and techniques is one root for their multidisciplinary use in a multidisciplinary unit. This fact includes the containment of costs by sharing a good part of equipment, staff, rooms and training modalities among different disciplines. Some existing units in Italy (Milano, Padova, Verona, Bologna) are demonstrating the absence of conflicting apportionments in room or time between the different specialities. The work-flow in an Interdisciplinary Endoscopic Department has its example in the centralized multidisciplinary operation units, widely in use in hospitals all over the world.

As consequence, there is an obligation to create a new curriculum now. It should consist of a basic training of about 2 years in various surgical disciplines and of a special training of about 3 years in a full-time stay at the operative unit of choice. At the end the trainee will emerge as a full‑endoscopist.

In Italy, the occupation in an endoscopic unit is considered as surgical activity and endoscopic operative interventions, such as polypectomy, sphincterotomy and others are recognized as surgical procedures.

Insurance companies do not longer cover endoscopic side-effects or complications if the contract was issued for internistic, not for surgical activities. The forensic interpretation of an endoscopic therapeutic action is surgical.

Our goal is the acceptance and recognition of endoscopy as an independent surgical speciality. We will fight with all our energies for this aim. We hope on your assistance.

May God help us!

Thank you !

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