Hands-On Workshop Center: Enteroscopy and Other Endoscopic Procedures

Hands-on sessions markedly enhance the CME experience. New to the ACG Scientific Meeting in 2010, the hands-on workshop center proved to be one of the conference’s most popular offerings.

Attendees registered for limited-attendance sessions with senior clinical teachers from distinguished referral centers around the country and were instructed by experts in less common or new clinical techniques, using porcine specimens, plastic models, or a combination. Sessions were offered in the use of endoscopic retrograde cholangiopancreatography (ERCP), hemostatic devices, banding and cap techniques, use of the flush knife and hook knife, and enteroscopy. For some, it was an opportunity to brush up, for others, it was their first experience with a new technology or technique.

For me, it was the latter. I finished internal medicine training in 1990, a moment in GI technology history when standard logic held that enteroscopy (direct visualization of the small intestine through an endoscope) was a difficult technical trick-and so endoscopy was limited to the colon and upper GI tract. The small intestine was viewed as being too long, too thin, too fragile, and too untethered to safely allow safe passage of then-current fiberoptic endoscopes and techniques. For my patients with unexplained GI bleeding and anemia, it was very difficult to rule out a small-intestine bleeding source from an arteriovenous malformation (AVM), short of the capsule-swallowing rigmarole (the “pill-cam”), which was minimally useful in any case.

All that changed in about 2005, when enteroscopy came into use. I took part in a hands-on enteroscopy teaching session with Patrick Okolo III, MD, from the Johns Hopkins University. Dr Okolo helped us sample the experience of navigating the small intestine’s 4 to 5 meters length, using a short segment of porcine intestinal specimen. It indeed looked flimsy and easily perforated (virtually transparent), and lying on a plastic tray, it was most certainly untethered.

But Dr Okolo is a gifted teacher and had several inexperienced operators comfortably passing the scope along the meter of esophagus, stomach, and intestine that had been prepped (in live patients, Dr Okolo stresses the need for impeccable bowel prep). The key to the technology is an “over-tube” and balloon system through which a thin fiberoptic viewing and instrumentation scope passes. The balloon and over tube are used to anchor the scope for advancement along the length of the intestine. By sequentially inflating, advancing, deflating, and then “accordioning” back the intestine, safe advancement in a long, flimsy, untethered lumenal organ is fairly easy.

Our porcine model was the upper GI system, so we navigated the esophagus, stomach, duodenum, and jejunum. In humans, enteroscopists can now routinely approach the small intestine through the upper GI tract, or through the lower GI tract, depending on where a lesion is suspected. Visualization of the entire small intestine is possible, but Dr Okolo recommends using both approaches sequentially to complete that procedure-it’s difficult to span the entire length of the small intestine from one end of the system.

Seeing the procedure’s relative simplicity suggests that this is an important diagnostic modality that those of us trained before 2005 will not be familiar with. The value of a hands-on approach (as opposed to lecture-only) was tremendous in creating a memorable and likely practice-changing CME experience.