Comment from Dr Jean-François Rey, WEO President: This informative article describes the impact of endoscopy on medical practice today. Professors Shutian Zhang and Peng Li from Beijing Friendship Hospital, Capital Medical University tell how endoscopy has evolved from a medical technique into a medical discipline in itself, and suggest that an integrated, multidisciplinary approach is necessary to accommodate the current holistic view of the human body.

 

Endoscopy – From a diagnostic tool to a specialty study. “Endoscopology” – Thoughts of Professor Shutian Zhang and Professor Peng Li

Professor Shutian Zhang 

Professor Peng Li

Beijing Friendship Hospital, Capital Medical University, Beijing, China

The evolution of endoscopes from rigid instruments to the current high definition and magnification devices has changed the field of endoscopy and the practice of medicine. “Endoscopy” is the technical practice of using endoscopes. It has changed our understanding of disease by observation of the inner surfaces of the natural lumen of the human body. This observation has evolved from macroscopic to microscopic, from monochromatic to polychromatic, from two-dimensional to stereoscopic and, in practice, from diagnosis to treatment.

If a polyp is found at endoscopy, the endoscopist should pay attention not only to the technical aspects – endoscopic appearance and the subsequent pathological results – but also to etiology, genetic variation, endoscopic classification, pathological type, treatment, prevention, and postoperative follow-up. Such activity is not simply the application of technique, it is a field of study in itself, and so should be termed “endoscopology.”

For a colorectal polyp, consideration must increasingly be extended from a single etiology to multiple etiologies, from a single organ to multiple organs, from one system to all of the human body, and from the individual patient to his or her associated environmental, biological, emotional, and behavioral conditions. This might be termed “integrative endoscoplogy.”

A definition of health from a holistic-humanist point of view is the maintenance of an integrated harmony amongst the systems of the human body, which is closely related to the individual’s flexibility in sustaining a dynamic or homeostatic balance. Illness is therefore conceived as the inability of the patient to integrate the systems in a balanced way.

A large number of components, including environmental, emotional, hereditary, personality, and lifestyle factors, influence the dynamic or homeostatic balance within the human body.

For example, for familial adenomatous polyposis (FAP), endoscopology should consider its hereditary nature, its natural history, emerging surveillance and management protocols, and chemopreventive strategies [1]. It is a hereditary condition with a nearly 100% lifetime risk of colorectal cancer unless prophylactic colectomy is done. Most patients with FAP have a mutation in the adenomatous polyposis coli gene on chromosome 5q22. The condition frequently presentsat a young age, with polyps developing most often in the second decade of life, and surveillance colonoscopy starting at age ten is required. Polyps are found not only in the colon but also in the stomach and duodenum. Knowledge of the natural history of FAP is important as there are several extracolonic sequelae which also require surveillance. Current chemopreventive strategies include several medications and natural products, although at this point there is no consensus on the most efficacious and safe agent. Genetic counseling is an important part of the diagnostic process for FAP: appropriate use and interpretation of genetic testing is best accomplished with involvement of a genetic counselor as many families also have concerns regarding future insurability or discrimination when faced with genetic testing.

To give another example, ERCP can be seen as simply a kind of technique: the best endoscopist is the one who works fastest, or who has the highest success rate. But some patients who undergo ERCP are prone to consequent pancreatitis. Understanding and minimizing the risks of post-procedure complications such as pancreatitis by the use of prophylactic stents or administration of rectal NSAIDs is important. Preoperative indomethacin can reduce episodes of post-ERCP pancreatitis [2], and the endoscopists who prescribe preoperative indomethacin to high risk patients are approaching ERCP in a broader context, that of the study of endoscopology.

This is why advances in areas of specialization must have an integrated systemic approach. An updated way of thinking has become necessary through the adoption of a current holistic view of the human body. From a systemic and integrated standpoint, “endoscopy” should change to “endoscopology,” from a technique to a discipline. Integrative endoscopology must widely involve different specialties, developing an interdisciplinary and/or multidisciplinary framework, in order to preserve and improve the quality of lives through enhanced interaction.

References

  1. Septer S, Lawson CE, Anant S, et al. Familial adenomatous polyposis in pediatrics: natural history, emerging surveillance and management protocols, chemopreventive strategies, and areas of ongoing debate. Fam Cancer. 2016;15(3):477-85.
  2. Hou YC, Hu Q, Huang J, et al. Efficacy and safety of rectal nonsteroidal anti-inflammatory drugs for prophylaxis against post-ERCP pancreatitis: a systematic review and meta-analysis. Sci Rep. 2017;7:46650.