Implementing interventional radiology-operated endoscopy into everyday practice
By Rajiv N. Srinivasa, MD, Jeffrey Forris Beecham Chick, MD, MPH, DABR, and Ravi N. Srinivasa, MD Spring 2018 (preview)
The role of the interventional radiologist as a specialist in minimally invasive, image-guided procedures is an ever-changing frontier. New and innovative treatment approaches are being developed every day. The imaging tools available to IRs have traditionally included ultrasound, fluoroscopy, CT and MRI. While gastroenterologists and urologists have incorporated the use of endoscopy into their clinical practice, its potential for use in IR has remained largely untapped.
Consider the request for placement of a cholecystostomy tube in a patient with acute cholecystitis caused by gallstones. These patients frequently have multiple medical co-morbidities that preclude them from undergoing surgical treatment and are occasionally committed to long-term cholecystostomy drains. The IR, however, may provide a minimally invasive option that avoids surgical cholecystectomy. After placing a temporary cholecystostomy tube in an acutely ill patient, the patient may be scheduled to return for IR-performed endoscopic gallstone removal. In such a position, the interventional radiologist has a tremendous opportunity to be the driver of these patients’ care after initial consultation. The goal is for the patient to live cholecystostomy-free, reducing both morbidity and mortality.
Incorporating endoscopy into your practice
In general, the initial percutaneous access created for any tube placement—biliary drain, cholecystostomy, gastrostomy or nephrostomy—may serve as a conduit for IR-performed endoscopy. The implementation of endoscopy into IR practice opens the door to a myriad of new and beneficial treatments for patients previously receiving only temporizing treatments.
The first step to establishing endoscopy in an IR practice is to be collaborative with other specialties. For example, offer to send referrals to the gastroenterologists if there is a case that would be better suited to transoral endoscopic retrograde cholangiopancreatography (ERCP). Often they will reciprocate when there are cases where there is difficult anatomy (e.g., patients with surgical biliary anastomoses or gastric bypass patients), where performing ERCP may be extremely challenging or perhaps even fail—percutaneous transhepatic biliary endoscopy may be a good alternative. Additionally, patients with indwelling cholecystostomy tubes who fail tube capping trials, have gallstones, and are not surgical candidates may benefit from cholecystoscopy and cholecystolithotripsy. In select patients, this has the potential to render them tube-free through a simple percutaneous endoscopic procedure without having to undergo a surgical cholecystectomy.
Biliary stone cases are probably the best starting point to build a percutaneous endoscopy practice. From there, endoscopy utilization may be expanded for a variety of other purposes. Interventional radiologists should tread lightly in the area of percutaneous nephrolithotripsy; however, this may be appreciated in some practices depending on the availability of an endourology service line. Additionally, endoscopes may be used for percutaneous nephroureteroscopy to assist with recanalization of difficult ureteral strictures, remove foreign bodies, or in the setting of postsurgical collecting system anastomoses, such as in patients with a pyelovesicostomy.
Endoscopy and the IR clinician
As experts in both imaging and image-guided treatments, IRs possess extensive knowledge of anatomy as well as the manual dexterity and coordination required to perform endoscopic procedures. Further, recent improvements in endoscope designs—including flexible and rigid endoscopes—have made their assembly and use very straightforward. As a result, the learning curve and barriers to incorporating endoscopy into an IR practice are significantly less than in the past. At our institution, for instance, IR attendings and trainees have learned to maneuver endoscopes and related endoscopic instruments while performing complex IR interventions. When consulting as a clinician on the patient care team to perform these treatments, though, IRs should not view themselves as just proceduralists, but as equal partners in analyzing each patient critically. For example, before every tube placement, the IR must first ask, “What is the plan to remove it?” The answer should be of equal importance to the patient and the physician. Sometimes the answer may involve treatment by another specialty; however, increasingly with the use of endoscopy in the field, interventionalists may be the ones to provide the definitive treatment.
Although institutional policies may play a role in determining what procedures the IR is permitted to perform, they should not hinder IRs from discussing these treatment options with referring physicians and patients. The referring physicians at institutions that do not routinely perform these procedures may be unaware that IRs are able to perform endoscopy; therefore, the duty falls on the specialty to educate their colleagues when the need arises.
A multidisciplinary discussion may involve surgery, gastroenterology and urology where appropriate. Frequently, since interventionalists have already created the percutaneous access they can treat these patients in a less invasive manner than other specialists. By taking ownership of these patients and providing consistent results, referral patterns will begin to change. When consulted appropriately, colleagues will continue to embrace the IR taking an active role in managing patients and the implementation of endoscopy in IR.
Equipment in endoscopy
Innovation has always been a pillar of IR, and the addition of endoscopy into the armamentarium of image-guided procedures may pave the way for many new treatments for a variety of diseases. The working channel of modern endoscopes allows the passage of a variety of devices, from baskets and snares to retrieve stones and foreign bodies, to lasers and ablation catheters. The continuous introduction of new devices for use with the endoscope will lead to novel therapeutic uses.
A variety of endoscopes exist—both flexible and rigid—with single-use disposable endoscopes available. The cost of most flexible reusable scopes is quite expensive; however, many of these scopes can be borrowed from other services such as urology or gastroenterology. A variety of the same fluid-based scopes that are used by many urologists can also be used for percutaneous biliary interventions and other percutaneous endoscopic interventions. Acquiring these reusable scopes for sole use by interventional radiology may be cost prohibitive initially until a service line is well-established. However, it should be relatively simple to borrow scopes and towers from the operating room, urologists, or gastroenterologists for potential scope cases. Additionally, some disposable scopes are relatively low cost ($1,500 for single use) and provide a 9.5-French flexible single-use scope with a 3.6-French working channel. The manufacturer provides a digital monitor for use for free if a certain quota of scopes is used routinely. This scope can be used for a multitude of different purposes including biliary endoscopy.
For more specific details on the equipment an IR should obtain to incorporate endoscopic procedures into their practice, contact the authors at firstname.lastname@example.org, email@example.com or firstname.lastname@example.org or visit the SIR Connect cholecystoscopy community at bit.ly/2FlnWao.
In general, the shortened hospital stays, avoidance of lifelong tube exchanges and avoidance of surgery are likely to substantially favor the incorporation of endoscopic procedures into most IR practices. Nevertheless, appropriate patient selection remains key to successful implementation.
The authors believe that the use of endoscopy in IR is an exciting frontier that will continue to expand and hopefully be embraced by the specialty, perhaps leading it to become as indispensable a tool as the many other imaging modalities interventional radiologists have at their disposal.
All photos courtesy of Jeffrey F.B. Chick and Ravi N. Srinivasa.
Although biliary endoscopy is unfamiliar to many IRs, others have employed it for years. Do you incorporate endoscopic IR into your practice? Log in and post your comment below!