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The Surgeon as Endoscopist

Gerald Marks, M.D. *

The incredible benefit that flexible fiberoptic endoscopy has brought

to the management of patients with gastrointestinal disease could not, in
the beginning, be anticipated. The ability to see and appreciate inflamma-
tory and neoplastic changes in the lumen of the gastrointestinal tract that
are undetectable by standard radiographic methods brought new under-
standing of the natural history of these diseases. Also, direct inspection
enables far more accurate diagnoses, and the technical features of the
endoscope allow definitive intervention in a range of situations with far less
risk and inconvenience to the patient than conventional surgical methods.
In sum, flexible fiberoptic gastrointestinal endoscopic diagnosis and therapy
have revolutionized patient management and become indispensable to both
surgical and nonsurgical treatment of digestive tract disorders.
Recognizing the many benefits of flexible fiberoptic endoscopy of the
gastrointestinal tract, the founders of the Society of American Gastrointes-
tinal Endoscopic Surgeons (SAGES), in their Statement of Purpose, ex-
pressed the conviction that endoscopy is an integral part of gastrointestinal
surgery. Events of the first two decades of clinically applied flexible
fiberoptic endoscopy underscore the wisdom of this belief. So integral to
surgery is endoscopy that its quality oftentimes determines the quality of
care the gastrointestinal surgeon can offer the patient. What better quality
control is there than having the surgeon also be a proficient endoscopist?
Advantages accrue to the patient when the surgeon, who shoulders the
ultimate responsibility for treatment, has visual knowledge of the problem
being treated and thereby is better equipped to make enlightened judg-
ments. Therefore, a constellation of factors provides the raison d'etre for
the" surgeon endoscopist."
Although there are those of us who understand this idea, a broad
display of reactions to the term "surgeon endoscopist" exists both inside
and outside the surgical community. On the negative side, there are those
outside surgery who have advocated restricting surgeons from performing

*Professor of Surgery and Director, Division of Colorectal Surgery and Comprehensive Rectal
Cancer Center, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania

Surgical Clinics of North America-Vol. 69, No.6, December 1989 1123

1124 GEHALD MAHKS

flexible gastrointestinal endoscopy. A historical review of attitudes toward,

perceptions of, and forces directed at the surgeon endoscopist can help to
bring understanding of the present problems and prospects. With under-
standing, surgical leaders should be better able to design a plan that will
bring status to the surgeon endoscopist and ensure that there can be no
threat to present and future endoscopic opportunities. Paving the way along
which surgery as a complete discipline will travel into the 21st century is
a significant consideration.

HISTORICAL PERSPECTIVES

When endoscopes were rigid and endoscopy was difficult, surgeons

were the endoscopists. Rigid esophagoscopy, bronchoscopy, and direct
laryngoscopy were performed by the otolaryngeal or thoracic surgeon.
Similarly, diagnostic and therapeutic thoracoscopy and peritoneoscopy were
performed by surgeons. Gastroscopy through rigid and flexirigid instru-
ments was the only distinctive endoscopic procedure performed by non sur-
geons.
Then flexible fiberoptic endoscopy was born, the essence of which was
a cold light passed through a system of lenses and glass fibers made flexible
by being drawn to an exceedingly narrow diameter. Flexible fiberoptic
technology brought instruments that provided extraordinary opportunities
to examine and treat gastrointestinal disease easily. Flexible fiberoptic
gastrointestinal endoscopy became the new mainstay of gastroenterologists,
and the practice of gastroenterology changed abruptly. With the changes
emerged a new breed of procedure-oriented medical practitioner, whose
zeal created a whole new set of problems for surgeon endoscopists.
In the pioneering period, gastroenterologists and surgeons collaborated
effectively to study the natural history of gastrointestinal disease and to
develop guidelines for the clinical application of flexible fiberoptic gastroin-
testinal endoscopy. In this unique instance where surgeons and nonsurgeons
used the same instruments and technology to treat the same diseases, the
cooperative spirit was admirable. With time, the rank and file of practicing
gastroenterologists-whose numbers had grown impressively, perhaps be-
cause of the glamour and economic potential of flexible endoscopy-began
to manifest turf consciousness. Economic considerations continued to
mount, adding to the political swirl, and in an unprecedented manner,
attempts were made to restrict surgeon endoscopists' opportunities. Acri-
monious editorials were published citing reasons why surgeons should not
perform endoscopy. The collaborative spirit of the multidisciplinary pi-
oneers drowned in waves of greed and ego. The economics, particularly in
academic environments, intensified the conflict. Medical schools were
understandably concerned about protecting the endoscopically generated
revenue that had become critical to the medical department budget.
The question of what constituted adequate endoscopic training became
a point of contention, the argument centering on the number of endoscopic
procedures performed during training. This was a legitimate concern and a
reasonable criterion for nonsurgeons but not at all appropriate for the
 THE SURGEON AS ENDOSCOPIST 1125

surgeon endoscopist. The surgeon, in the course of 5 or more years of

residency training, regularly holds, cuts into, exposes, and inspects the
interior; resects; replaces; and repairs the hollow smooth-muscle viscera of
the gastrointestinal tract. The resulting familiarity with the anatomy,
texture, resilience, compliance, and strength of tissues, as well as with
gross lesions, is an enormous advantage and confers an advanced standing
on the surgeon as a student endoscopist. The surgeon's potential for learning
endoscopy is clearly superior, and the number of endoscopic procedures
carried out thus is not critical.
It should be emphasized, however, that surgeons cannot, by virtue of
their surgical ability alone, consider themselves competent endoscopists.
To become a proficient endoscopist, the surgeon, like the nonsurgeon,
must make the necessary commitment in time and education (training).

ASSERTING THE ROLE OF SURGEON ENDOSCOPIST

In 1980, surgeon endoscopists, alert to the importance of gastrointes-

tinal endoscopy in the management of surgical patients, and sensing the
forces that endangered the surgeon endoscopist as a species, saw the need
to ensure forever the rights and privileges of surgeons who wished to
perform gastrointestinal endoscopy. The Society of American Gastrointes-
tinal Endoscopic Surgeons was incorporated in 1981 after more than a year
of intense planning by surgeons from every sector. Their purpose was to
provide a framework for educational and research programs, as well as
guidelines for the clinical application of flexible fiberoptic gastrointestinal
endoscopy in surgery. The surgical presence in gastrointestinal endoscopy
had been assured by the organization for the moment.
Unfortunately, surgeons did not readily see a clear, practical means of
integrating the new methodology with traditional procedures, and the
number of surgeons involved remained modest. Meanwhile, pockets of
repression continued to force surgeon endoscopists to work in suboptimal
environments, to refrain from performing endoscopy altogether, or to
abandon endoscopy in exchange for patient referrals. Thus, although the
Society has grown to a thousand members, pursuit of fair practices remains
a necessity. It is interesting that practices restrictive to surgeon endoscopists
are not limited to this country but are alive worldwide.
Whether the gastrointestinal endoscopist is perceived as a surgeon or

I
a nonsurgeon by primary physicians depends in large part on whom they,
as medical students and house staff officers, saw in that role. Images are
etched on the minds of students and house staff physicians, and we must
remember that these are the individuals who will set the policy of tomorrow.
It would be well to accustom students and residents to seeing surgeons as
players on the endoscopy scene. If surgeon endoscopists are to establish
and maintain a rightful place in the medical world, they must enjoy a
presence in academic settings. Surgical department chairmen could help in
this regard were they to attach importance to gastrointestinal endoscopy
and accent the educational and research efforts of surgeon endoscopists. A
surgeon endoscopist teacher should be a basic element in every surgical
1126 GERALD ~ARKS

residency program to provide the proper visibility and to assure proficiency

in flexible fiberoptic gastrointestinal endoscopy in each resident, who would
otherwise be forever denied the opportunity to obtain it.

GOALS OF PATIENT CARE

If the best interests of patients are to be served and hospital resources

are to be expended intelligently, innovative administrative approaches are
needed to re-establish the cooperative spirit between surgeons and gas-
troenterologists. Expensive new technology must be shared rather than
replicated. The necessary quality assurance programs and peer review can
be either multidisciplinary or unidisciplinary. The potential for scientific
growth should be limited only by the energies and imagination of the
individuals themselves. Neither surgeon nor nonsurgeon should exist at the
pleasure of the other. Surgeons and non surgeons would do better to ignore
their competitive differences and singlemindedly focus on the need for
proficiency in performing gastrointestinal endoscopy.
A review of surgically relevant flexible endoscopy procedures convinc-
ingly demonstrates the intrinsic value of endoscopy to surgery and under-
scores its importance to the surgeon. The panoply of clinical applications
of flexible gastrointestinal endoscopy in the management of the surgical
patient is staggering: a list of excessive length would be needed to describe
all the applications.
Pointing only to the unique applications, we will begin with examina-
tion of the esophagus. Premalignant or early malignant lesions can be
detected, cancers of the esophagus can be staged by visual inspection and
endoscopic ultrasound, intraluminal bypass prostheses can be introduced,
and sites of lesions can be localized to aid in planning surgical techniques.
Benign and malignant strictures can be calibrated and dilated. Variceal
hemorrhage can be sclerosed, and other types of bleeding can be controlled
by various means. Endoscopic assessment of esophagitis enables timing of
surgical intervention for reflux.
Endoscopic access to the stomach permits localization of benign and
malignant lesions, particularly those with an anatomic relation to the cardia,
a point vital to planning surgical techniques. Anastomotic strictures can be
calibrated and dilated. Endoscopic ultrasound permits assessment of the
depth of involvement of gastric cancer and allows patient selection for local
treatment, including laser destruction, of early cancer. Foreign bodies can
be removed and postoperative configurations assessed. Percutaneous en-
doscopic gastrostomy is proving valuable. Endoscopic ultrasound through
the stomach may provide useful information about pancreatic abnormalities.
Staining techniques permit appreciation of the completeness of vagotomy
and early gastric cancer.
Endoscopic examination of the duodenum permits exploration of the
ampulla of Vater and radiographic assessment of the common bile duct and
pancreatic ducts. The release of ampullary strictures, papillotomy, extrac-
tion of common duct calculi, and decompression of the duct of Wirsung for
pancreatitis are other procedures of surgical interest that can be carried out
THE SURGEON AS ENDOSCOPIST 1127

with the endoscope. The full impact of endoscopic ultrasonography through

the duodenal wall to evaluate pancreatic and other retroperitoneal diseases
with surgical implications is not yet known.
Colonoscopic evaluation has revolutionized the management of colo-
rectal disorders, of which colorectal neoplasia is the most important.
Detection of polyps and of early and mature cancers that may have been
missed by roentgenographic methods is a well-known benefit of endoscopy.
Colonoscopic polypectomy is probably the endoscopic procedure that has
had the greatest impact on gastrointestinal disease management. Removal
of foreign bodies and decompression of Ogilvie's syndrome and volvulus
are other surgically oriented applications. Endoscopic ultrasonography and
the laser have tremendous potential in the management of colorectal
problems. Laparoscopy as a surgical tool has yet to be explored adequately.
The important cognitive aspect of surgery requires that the surgeon
use all available information in formulating treatment plans. Because
accurate endoscopic data frequently are vital to the surgeon's perceptions
and judgments, endoscopy becomes an important means, not an end, for
the surgeon endoscopist.
For many reasons, flexible fiberoptic gastrointestinal endoscopy is a
tool of practical value to surgeons. By dint of training, mindset, and
experience, surgeons are well suited to use this tool, but they will not be
able to do so unless they achieve a level of endoscopic proficiency during
their surgical residency that enables them to become credentialed.
Because extraordinary benefits accrue to the patient when the surgeon
has an opportunity to view first-hand the site of disease, it follows that the
gastrointestinal surgeon must be a proficient endoscopist and that endoscopy
must be an integral part of gastrointestinal surgery. Leaders of surgical
organizations and surgeon educators, upon whom rests the responsibility
for shaping policy and educating medical students and residents, should
remain alert to the need to maintain a substantial surgical presence in the
area of gastrointestinal endoscopy. This presence can be maintained by
according appropriate status to flexible fiberoptic gastrointestinal endoscopy
in the medical school environment and in surgical residency programs and
by affording visibility to the surgeon endoscopist as a valued contributor to
surgical care. The ultimate goals are several: to assure an accurate percep-
tion of the surgeon as endoscopist; to prepare every surgical resident for
proficiency in flexible fiberoptic gastrointestinal endoscopy; and to have on
site a surgeon endoscopist teacher in each surgical residency program. The
future of all surgery and the continued best interests of patients demand
that we achieve these goals.
Division of Colorectal Surgery
Thomas Jefferson University Hospital
HOO Walnut Street, Suite 700
Philadelphia, Pennsylvania 19107