All About Advanced Surgical Endoscopy
Endoscopic procedures have undergone a multitude of innovations over the past several decades. Jeffrey Ponsky, MD shares the history of these surgeries and how everything from balloons to video capsules are now being used to treat complex GI disorders.
All About Advanced Surgical Endoscopy
Scott Steele: Butts and Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end.
So hi everybody, and welcome again to another episode of Butts and Guts. I'm your host, Scott Steele, the Chair of Colorectal Surgery here at Cleveland Clinic in beautiful Cleveland, Ohio. And we're very pleased to have Dr. Jeffrey Ponsky here today, who's the Lynda and Marlin Younker Chair in Developmental Endoscopy. Jeff, welcome to Butts and Guts.
Jeffrey Ponsky: Thank you, happy to be here.
Scott Steele: So we always like to start out with our guests, tell me a little bit about your background and where are you from, where'd you train, how'd you come to the point that you're here at the Cleveland Clinic?
Jeffrey Ponsky: So I was born in Cleveland, went to Case Western Reserve Medical School, did my training at Case Western Reserve, was the chairman of the department of surgery at Mount Sinai Hospital here in Cleveland for 18 years, then came to the Cleveland Clinic as director of minimally invasive surgery. After eight years moved on to University Hospitals in Cleveland, where I was the chair of the department of surgery for 10 years. And now I'm back at the Cleveland Clinic for the last 5 1/2 years.
Scott Steele: Well, we'll get a little bit into Cleveland later, but you've spent a large majority of your life here and we're so glad to have you here at the clinic. So for our listeners, we're going to talk about endoscopy today, and specifically a little bit more about advanced endoscopy. So can you give a general overview of what takes place during an endoscopic examination? And we'll get into the procedures a little bit later, but just walk us through that.
Jeffrey Ponsky: Well, years ago in the beginning of the last century, people were interested in what was going on in the gastrointestinal tract, and they took rigid tubes and had to contort the patient to align with these tubes so that they could look inside the esophagus and the colon. And it was quite uncomfortable. Then midway through the last century, people developed fiber optic technology, which allowed these tubes to be flexible. So then people began to look within the gastrointestinal tract from above and below to assess diseases that they were treating medically, diseases like esophagitis or esophageal cancer or gastric tumors or gastritis. And then the bottom end they were looking at colon cancer and causes of colonic inflammation and diarrhea, for example.
Then suddenly we had the development of therapeutic options through these tubes. People first did little pinch biopsies to assess the activity of disease and then found out that they could put an electric wire in and surround a polyp, for example, and actually take out a polyp that previously required surgical removal. They became a bit more brave and took these same technologies to the upper gastrointestinal tract and saw bleeding ulcers, for example, which they could coagulate and prevent the need for surgery. And further on they decided they could take out gallstones from the bile duct by opening up the bottom of the bile duct through the endoscope and pulling out these stones. And these procedures have continued and continued to grow and become more complex.
Scott Steele: Yeah, it's incredible, some of the things. And as technology has driven some of those advances in medicine, like along various different parts of medicine. But with that as an overview and a background, let's just touch base, some high-end, because there's a lot of patients that get told that they're going to have to have a certain procedure. And they go online and they want to know exactly what is this about. And so let's run through a couple of these and just tell us a little bit about what they treat and what can be expected from the patient's standpoint. So first of all, a balloon-assisted enteroscopy.
Jeffrey Ponsky: Well, very often we have a need to look at the small intestine. That is the spot between the stomach and the colon. And that is a difficult area to assess. And sometimes it's the source of bleeding, can even be the source of a tumor. And it's very difficult to get to. We now have the balloons that go on the outside of these endoscopes, which inflate and deflate and can walk down the intestine a farther degree than we can do with normal scopes, and actually look at this and actually allow us to treat certain lesions at these distant areas.
Scott Steele: Now, just to throw one in here that is not necessarily the same type of procedure we're talking about, but people might hear it, a video capsule endoscopy.
Jeffrey Ponsky: So again, the small bowel, again, is an area of which we can't get to very well. And so when someone has, for example, bleeding, and we can't find the source with an upper endoscopy or a colonoscopy, we'll often have them swallow a pill that looks like a big capsule. This has a flashing light that takes pictures very often, and it goes onto a record, and we can assess the small intestine and look for these otherwise hidden areas that can be bleeding.
Scott Steele: So when patients get that video capsule endoscopy, that's not one that the doctor actually does something about? They're given one of these small cameras and they do it at home?
Jeffrey Ponsky: The capsule is put in or swallowed, depending on the physician's preference, and they wear a monitor on their hip. And they bring this back after a couple of days and it's assessed.
Scott Steele: What about an ERCP, or endoscopic retrograde cholangiopancreatography?
Jeffrey Ponsky: Well, this is what I was referring to before. The bile duct that carries bile from the gallbladder and liver empties into the first portion of the small intestine, called the duodenum, which is in the reach of the upper endoscope. And we've often looked at the little opening that the bile comes out of, and when that bile duct is somehow compromised by a stone or a tumor, we can pass a little tube into the opening at the intestine, inject dye, see what the problem is, and very often take care of it. That's called ERCP. We can cut the opening at the bottom and pull stones out. If we see tumors, we can often define them by biopsying them or putting in a little plastic or metal stent to keep the area open.
Scott Steele: Along the lines of that, endoscopic ultrasound. Is that performed at the same time?
Jeffrey Ponsky: This is an area that has really grown in the last two decades. It allows us to look beyond the intestine at the organs next to the intestine, like the bile duct and the pancreas in particular, and the wall of the stomach and adjacent vessels, so that we can see tumors that we wouldn't otherwise recognize just by looking. We can even biopsy them as well.
Scott Steele: How about POEM procedure, peroral endoscopic myotomy?
Jeffrey Ponsky: POEM has become, in the last 10 years, it's really an exciting area. Because now we've taken the endoscope and we've started to do real surgery through it. Not just looking, not just biopsy, but really operating. And this procedure allows us to take an area of the esophagus where the esophagus is diseased and won't work normally, won't open, where we'd previously do an operation through the abdomen to cut the muscles of the lower esophagus to allow the food to go through. We can now do it through the mouth by making a tiny incision in the swallowing tube, the esophagus, on the inside of the esophagus, and wiggling down through the esophagus and actually cutting the muscles, and then closing the esophagus on the inside and sending the patient home right away without the need for any surgery through the abdomen at all.
Scott Steele: Couple of procedures that oftentimes are said together, a EMR or an ESD.
Jeffrey Ponsky: So these are alphabet soup that, again, we're starting to do real surgery with the endoscope. And the endoscope is the vehicle, like the car that gets you to work. But once we get there we're doing surgery. So the EMR, endoscopic mucosal resection. If we see a tumor when we look into the intestine, we can shave it out. That's EMR. But if the tumor is flat and long and broad, we can do a better cancer operation or a pre-cancer operation by lifting up that tissue and shaving it out down to the next layer. These have been proven to be safe and effective and, again, avoid the need for open surgery.
Scott Steele: So let's take a walk down memory lane, and tell us a little bit about maybe the history and something behind a procedure called a PEG tube.
Jeffrey Ponsky: Well, again, this was one of the first endoscopic surgical interventions. And we often were called upon 40 years ago, and still are, for patients who can't eat because of neurological problems or oral problems, they need a feeding tube placed in their stomach. That required an open operation on the abdomen. Michael Gauderer, who's a pediatric surgeon, and myself were lucky enough to think of a procedure where we could use the endoscope to guide a needle puncture of the abdomen and put a tube right into the abdominal wall, into the stomach, without the need for surgery. This is called a PEG, percutaneous endoscopic gastrostomy. It remains much unchanged today, but really the significance of it is, it told us we could do surgery using the endoscope as a vehicle.
Scott Steele: And what were you doing when you guys thought of that particular procedure? Did your light bulb shine on, or was it kind of a gradual evolution?
Jeffrey Ponsky: The light bulb is a good analogy, because we actually were doing this in very little babies who had brain-damaged births and they required endoscopy for some reason or other. The room lights were dimmed, and we saw this bright shining light coming through their abdomen, and we pushed with our finger. We realized we were in close contact with the stomach, and we realized that if we put a needle through there, we could accomplish the procedure. So the light did lead us to the method.
Scott Steele: That's actually a fantastic story. So I know a lot of these procedures are performed maybe when a patient is admitted to the hospital, but a lot of them are done, as you said earlier, as an outpatient. So let's take the scenario first where a patient's in outpatient, they see their physician or their gastrologist or their surgeon and they're told they need one of these procedures. Walk me through what a patient will have to do to. Do they all have to have a bowel prep? Are they kept NPO? And what are some of the risks of these particular operations?
Jeffrey Ponsky: Well, this is surgery. As I said before, the endoscope is the vehicle that gets us there, but now you're dealing with surgery. And everything we do to anybody has certain risks, and always bleeding or puncture or perforation are those risks, or infection. We're starting to do these procedures as outpatients in many cases. And some of the newer procedures we're doing are very bold and very advanced. For example, we are able to open the bottom of the stomach, called the pylorus, and open that muscle in the same way we do the POEM, in the intramural space inside the wall. We cut the thick muscle that won't open, clip it closed, and the patient goes home the same day and their stomach empties better. That's an outpatient procedure. The only preparation is a liquid diet for two days before, and afterward they stay on a liquid diet for a week.
Similar procedures are done, we have patients who have out-pouchings in their neck called Zenker's diverticulum, which required a big operation in the neck before. Again, we do this through the mouth now. We make a little incision inside the back of the throat, we cut the thick muscle that's holding back the swallowing and clip it closed, and the patient can go home right away. Again, the preparation is a couple of days of liquids before the surgery and a week of liquids after. We are learning to do these procedures as outpatients or overnight stays in almost every case.
Scott Steele: So when you take a look at a lot of these different procedures, where do you think we're going to go on the horizon? I've read everything from taking care of bowel connection or anastomotic leaks. I've read about weight loss surgery, we've done this. So what's the next steps in terms of this? As a surgeon, am I going to have to be worried about my future job?
Jeffrey Ponsky: Yes. Everything that we do surgically today is being looked at in a less invasive, endoscopically guided fashion. And in the future, again, much like in regular surgery, robotics will play a role. This will be image-guided surgery, robotically assisted surgery, even robotically controlled surgery, which will make the movements more precise and give us better results. So we're in a transition stage now. Technology, innovation, and human thought will lead us to less invasive ways to do surgery. The way we do surgery today is not anything like we did 100 years ago, nor will it be in 100 more years.
Scott Steele: So take a look at what's happening here at the Cleveland Clinic and with your team of surgical endoscopists, and what research are you going on right now and what can we see coming out of the clinic?
Jeffrey Ponsky: So we're doing evaluation of these procedures. It's not enough to just come up with a new procedure. We're constantly improving these procedures that I spoke to you about, this intramural surgery. We're improving them, we're perfecting them, and we're using integration of new technology in these procedures to improve their results.
Scott Steele: Well, that's actually fantastic stuff. And so we always like to wind up with each of our guests a little bit about yourself with some quick hitters. So Jeff, what's your favorite meal?
Jeffrey Ponsky: Sloppy Joes.
Scott Steele: What's your favorite sport?
Jeffrey Ponsky: I like watching football.
Scott Steele: What's the last nonmedical book that you've read?
Jeffrey Ponsky: Oh, I read a lot of them. The last one I read was Founding Fathers, which is a great history of the United States in the early years.
Scott Steele: And as we said at the beginning of this podcast, you have a long history here in Cleveland. Tell one of the things to the listeners that you really enjoy about Cleveland.
Jeffrey Ponsky: Cleveland is a wonderful place to raise a family. I have four children and 10 grandchildren all based in Cleveland, and it's a wonderful place to have them grow up and enjoy each other, as we all have great careers.
Scott Steele: I could not agree more. So Jeff, final thoughts on surgical endoscopy for our listeners.
Jeffrey Ponsky: Surgical endoscopy is just another way to do surgery. Much as we do a cystoscopy in the bladder or any other type of ear, nose, and throat surgery, the endoscope is the vehicle which gets us to the place where we have to do the surgery. We're constantly evolving this.
Scott Steele: Fantastic stuff. So for more information on endoscopic or other gastrointestinal procedures at the Cleveland Clinic, please visit clevelandclinic.org/digestive. That's clevelandclinic.org/digestive, D-I-G-E-S-T-I-V-E. And to make an appointment with a specialist in the Digestive Disease and Surgery Institute, please call (216) 444-7000, that's (216) 444-7000. Jeff, thanks for joining us on Butts and Guts.
Jeffrey Ponsky: My pleasure.
Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts and Guts.