Medicine (Austin & Northern Health) - Theses
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ItemNovel approaches to the endoscopic management of gastrointestinal disorders( 2017)Endoscopy has evolved since its humble beginnings. Over the past decade advances include the rapid evolution in endoscopic visual assessment of the bowel and its role in the management and prevention of colorectal cancer. Endoscopy has developed key diverse technologies that include capsule endoscopy and endoscopic ultrasound. Innovation and advances have not been limited to the endoscopes themselves but increasingly the devices that are utilized during endoscopy help to extend the boundaries of both diagnostic and therapeutic interventions. The aim of this thesis is to assess new and novel endoscopic techniques and technologies in the management of gastrointestinal disorders. The first area of study is to assess novel endoscopic techniques and technologies in the area of colonoscopy. This procedure is of key importance in Australia where despite having one of the highest rates per capita of colonoscopy worldwide, colorectal cancer remains the second most commonly diagnosed malignancy. Given that there is no contemporary local data on colonoscopy and polypectomy practices, we first undertook a national survey of practising endoscopists to assess whether significant variations in colonoscopy and polypectomy practice exist across Australia. The second area of study is whether prediction of colonoscopy surveillance intervals based on real time endoscopic assessment of polyp histology is safe, feasible, accurate and cost effective. A prospective cohort study was performed across public and private centres, 94 patients who underwent colonoscopy and polypectomy of diminutive (<5mm) polyps were recruited, yielding a total of 159 polyps. These polyps are interrogated with narrow band imaging (NBI) which is an optical assessment technology and classified as adenomatous or non-adenomatous according to the Sano-Emura classification system. The endoscopic assessment of histology is used to predict appropriate surveillance intervals. Accuracy of optical diagnosis of diminutive colonic polyps is measured against the gold standard histological assessment. The final study examines the utility of colonoscopy through a prospective multi-centre observational study of right-sided colonic retroflexion and its impact on polyp detection in 1351 consecutive adult patients undergoing elective colonoscopy. Withdrawal from the caecum is performed in the forward view initially and identified polyps removed. Once the hepatic flexure is reached the caecum is re-intubated and the right colon assessed in the retroflexed view to the hepatic flexure. Adenoma detection (ADR) and polyp rate (PDR) in the retroflexed view is compared with forward view examination of the right colon to assess if there is a significant improvement. The second line of investigation of this thesis examines the role of novel endoscopic techniques and technologies in the management of oesophageal and gastric cancers. The first study assesses the feasibility of endoscopic ultrasound (EUS) guided fiducial placement for the multidisciplinary management of gastric cancer. A prospective phase II feasibility study is undertaken in consecutive adult patients with primary gastric adenocarcinoma. Gold fiducial markers are inserted under EUS guidance into the margins of the gastric cancer primary tumour. The main outcome is the successful insertion of the fiducial without complications for response assessment and anatomic localization. The second study sought to address the limitations identified with EUS guided fiducial insertion and assess the utility of a novel marker inserted via a gastroscope for the multidisciplinary management of oesophagogastric cancer. The third and final area to be assessed in this thesis is the use of novel endoscopic devices in the management of upper gastrointestinal disorders. The first study examines the ability for risk stratification of upper gastrointestinal bleeding with an esophageal capsule. A diagnostic, nonrandomized, single-blind (investigator) study is undertaken across three tertiary centres. Eighty-three consecutive adult patients referred for management of upper gastrointestinal bleeding (UGIB) undergo a capsule endoscopy (CE) prior to gastroscopy for the investigation and management of UGIB. The main outcome measures are the detection rates of UGIB source and identification of a low-risk group of patients who may be suitable for outpatient gastroscopy based on CE findings. The second study assesses the management of pancreatic fluid collections (PFCs) with a novel endoscopically placed fully covered self-expandable metal stent (FCSEMS). A retrospective case series is undertaken across thirteen tertiary and private health care centres. Forty-seven patients undergo endoscopic management of PFCs with a recently developed lumen-opposing, fully covered self-expandable metal stent (FCSEMS). The main outcome measures are the technical and clinical success rate, adverse event rate. The aim of this thesis is to assess novel endoscopic innovations and their impact on gastrointestinal disease. Through the studies that will be presented we aim to demonstrate current techniques that can be rapidly incorporated into current clinical practice with significant impact, niche techniques with tremendous potential and novel devices, which exist in current clinical practice without adequate evaluation. Innovation is a key element to the evolution of endoscopy, however it must be evaluated within a formal framework to ensure optimal patient outcomes whilst remaining cost effective to our health system.