Guest Editor: The Endless Potential of Gastroenterology

To envision what’s possible, one must only look at how far we’ve come.

Albert Einstein once said, “Imagination is everything. It is the preview of life’s coming attractions.” Nowhere is that more true than in surgery — especially in gastroenterology.

Operative care over the past few decades has been progressively moving toward simplification and precision in its delivery. Of course, that hasn’t always been the case. It wasn’t too long ago when surgeries would routinely remove a significant percentage of the human body.

Incrementally, year by year, that has improved through less invasive and more efficient procedures. Surgeries like radical mastectomies have given way to lumpectomies. A large scar from an open cholecystectomy was once the norm; it is now replaced by tiny little punctures. Not to mention surgeries for peptic ulcer disease with intimidating names like Billroth-2 are now confined mostly to the annals of medicine.

Admittedly, gastroenterology has been a bit slow to embrace the increasingly progressive dogma in health care that other service lines have welcomed with open arms. As medicine progressed and shied away from the cut, the transoral or trans-sphincteric nature of our field promised boundless potential from the outset and guaranteed that more and more therapeutics would be added to the armamentarium of our specialty. In many ways, however, we’ve been limited solely by the imagination of the endoscopist. Luckily, that is changing for the better.

Back in the ’90s, the most common procedure in GI was sigmoidoscopy. Since then, a vast wave of creativity has fueled further advancements in procedures in our field. Diagnostic endoscopies were just the beginning. An entire book could be written on the myriad of therapeutics that can now be performed via these vessels, and the horizon just keeps broadening. Procedures like endoscopic submucosal dissection (ESD), natural orifice transluminal endoscopic surgery (NOTES) and the weight-loss intervention of esophageal-sparing intragastric balloon placement are commonly performed today. Once primarily discussed in the corridors of academia, these procedures are moving increasingly into the mainstream.

As a witness to the advent and advancement of therapeutic endoscopy over a quarter-century, I can vouch that the only limit to the application of these procedures in the outpatient setting are the financial shackles imposed by CMS. Other than that, their safety and ease have been proven over and over in that arena.

I can safely say that the majority of GI procedures fit nicely into this playpen of outpatient care.

As the CEO of an ASC franchise, I have dealt firsthand with nearly all surgical specialties. I’ve seen ASCs perform the simplest ophthalmology procedures all the way up to significantly complex spinal and orthopedic surgeries. I can safely say that the majority of GI procedures fit nicely into this playpen of outpatient care.

Transoral incisionless fundoplication (TIF), lumen-apposing metal stents (LAMS) drainage and pancreatic necrosectomy are moving to the outpatient world. Endoscopic sleeve gastroplasty (ESG) is already there, while procedures such as duodenal mucosal resurfacing (DMR) are on the horizon.  We are all bound only by the limits of our imagination, and gastroenterology has an abundance of that.

Just look at endolumenal surgery, a field that has seen a boom in innovation and fostered numerous new procedures that have reduced the need for surgical intervention. This has been best displayed within third-space (also known as submucosal) endoscopy and the variety of procedures focused on peroral endoscopic myotomy (POEM). Furthermore, translumenal endoscopy using LAMS for endoscopic drainage of fluid collections, the creation of anastomoses and other indications like endoscopic IBD therapeutics have significantly reduced patient morbidity, length of stay and the need for more invasive surgical procedures.

The Second Law of Thermodynamics does apply to the migration of procedures from hospitals to ASCs. Rather than entropy, progress will only move toward order in outpatient surgery. As we delve deeper into this subject in this Outpatient Surgery Magazine Special Edition on Gastroenterology, you will see the limitless innovations and applications that are opening up in our field, and how seamlessly they are becoming integrated into our realm.

Antoine de Saint-Exupéry, the French aviator, poet and author (The Little Prince), once said, “Perfection is achieved not when there is nothing more to add, but when there is nothing left to take away.”

Gastroenterology embodies that perfection. OSM