Surg Endosc (1992) 6:2-3
Surgical Endoscopy © Springer-Verlag New York Inc. 1992
What should a "surgical endoscopist" do? The surgical endoscopist should perform endoscopy Endoscopic evaluation and treatment of surgical diseases is an integral part of modern surgical care. Rigid endoscopy (e.g. bronchoscopy, esophagoscopy, choledochoscopy, cystoscopy, arthroscopy) has long been the purview of the surgical specialist. Flexible fiberoptic technology, which now allows simpler and safer endoscopic intervention, has greatly expanded our diagnostic and therapeutic options. These improved endoscopic techniques have been rapidly incorporated into the training programs and surgical practices of those specialties (e.g. orthopedics, urology) whose medical colleagues do not use rigid endoscopes [1]. Unfortunately, the introduction of flexible endoscopy into those surgical practices (e.g. general surgery, thoracic surgery) whose medical counterparts also practiced rigid endoscopy (e.g. gastroenterology, pulmonary medicine) was delayed by competition for patients and training opportunities, economic and political conflicts, as well as an apparent or perceived lack of surgical interest [1, 2]. Endoscopy of the gastrointestinal tract has particularly engendered significant controversy and interspecialty rivalry. The treatment of gastrointestinal disease has been dramatically influenced by fiberoptic endoscopic technology: Premalignant or early malignant lesions of the esophagus, stomach, duodenum, or colon can be discovered and proven histologically. Critical surgical decisions can be greatly facilitated by endoscopic evaluation of esophagitis, by localization of gastric lesions in close proximity to the cardia, and by intraoperative endoscopy in patients with occult gastrointestinal bleeding [3]. Assessment of gastrointestinal tumor resectability may prove to be enhanced with endoscopic ultrasonography [4]. Variceal sclerotherapy, percutaneous endoscopic gastrostomy, stricture dilatation, foreign body removal, endoscopic sphincterotomy, biliary endoprosthesis insertion, colonic polypectomy, and most recently, laparoscopic cholecystectomy, are but a few examples of how endoscopic technology has altered our therapeutic approach to gastrointestinal disease. Postoperative surveillance is of obvious import in follow-up of colonic neoplasia. Thus, endoscopic procedures are essential to the proper care - - be it medical or surgical - - of patients afflicted with gastrointestinal disorders
and are, therefore, a critical component in the armamentarium of the surgical practitioner addressing gastrointestinal ailments. The surgical endoscopist should teach endoscopy Recognizing the import of endoscopy, the American Board of Surgery specifies that "the General Surgeon must be capable of employing endoscopic techniques, particularly proctosigmoidoscopy and operative choledochoscopy, and must have experience with a variety of other endoscopic techniques such as laryngoscopy, bronchoscopy, esophagogastroduodenoscopy, colonoscopy, and peritoneoscopy [5]". Thus, surgical residency program directors have an obligation to provide endoscopic training for their residents. This obligation is underscored by the fact that general surgeons are more likely to practice in small, nonmetropolitan areas than are medical specialists [1, 6]. The general surgeon, therefore, may be the only available trained endoscopist in the area [1, 6]. Endoscopic training programs can be of variable structure. One design creates rotations for surgical residents on gastroenterology services [6]. While acceptable within some training programs, such an arrangement may inadequately support surgical needs [7], creating rotations where surgical residents are regarded as "second class citizens" [8] and/or where gastroenterology instructors are unfamiliar with the surgical considerations germane to certain endoscopic procedures [1, 8]. For these reasons, many programs have opted to create a separate surgical endoscopy service with a designated surgical endoscopic instructor [1, 9]. Formal surgical endoscopic training can be obtained through an integrated experience, a separate endoscopic rotation, a fellowship following residency, or an individually arranged preceptorship [I]. Although each option has relative advantages and disadvantages [1], the exact nature of the endoscopic training program must depend on the circumstances involved. Surgical residents, whose daily routine requires manual dexterity and handling of tissues, rapidly develop safe endoscopic skills [7]. Further, the typical university program offers sufficient clinical material to provide training in surgical endoscopy [10]. Endoscopy is rapidly integrated into surgical resi-
dents' patient care and thus is a vital component of their surgical training. With the expansion of endoscopic and laparoscopic interventions, it is particularly important that surgical training programs aggressively integrate this educational obligation. The surgical endoscopist should participate in endoscopic research The excitement and explosive interest generated by laparoscopic cholecystectomy demonstrates how surgical endoscopic research has expanded our therapeutic options while improving patient care. The American Board of Surgery indicates that "it is desirable that the General Surgeon have opportunity, whenever possible, to gain some knowledge and experience of evolving technological methods, e.g. laser applications, lithotripsy, and endoscopic operations" [5]. Thus, surgical endoscopists have an obligation not only to our patients, but also to our pupils to continue endoscopic research. We must strive to remain at the forefront of ongoing technological innovation. Aaron S. Fink
References 1. Dent TL, Kukora JS, Leibrandt TJ (1989) Teaching surgical endoscopy of the gastrointestinal tract. World J Surg 13: 2022O5 2. Marks G (1989) The surgeon as endoscopist, Surg Clin North Am 69:1123-1127 3. Bowden TA, Hoods VH, Mansberger AR (1980) Intraoperative gastrointestinal endoscopy. Ann Surg 191:680-687 4. Tio TL, Tytgat GNJ, Cikot RJLM, et al. (1990) Ampullopancreatic carcinoma: preoperative TNM classification with endosonography. Radiology 175:455-461 5. American Board of Surgery, Inc.: Booklet of Information. Philadelphia, PA; July 1990-June, 1991 6. Schwesinger WH, Levine BA (1984) Endoscopy training in a general surgery program. Results of a survey. Arch Surg (1984) 119:384-386 7. Starling JR, Morrissey JF (1982) One solution to the dilemma of endoscopic requirements for general surgical residents. Surg Gynecol Obstet 155:65-66 8. Max MH, Polk HC, Jr (1982) Perceived needs for gastrointestinal endoscopic training in surgical residencies. Am J Surg 143: 150-154 9. Ponsky J (1988) The incorporation of endoscopic training into a surgical residency. Newsletter of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Spring, 1988; p. 2 10. Smale BF, Reber HA, Terry BE, et al. (1983) The creation of a surgical endoscopy training program - - Is there sufficient clinical material? Surgery 94:180-185
Surgical Endoscopy © Springer-Verlag New York Inc. 1992
What should a "surgical endoscopist" do? The surgical endoscopist should perform endoscopy Endoscopic evaluation and treatment of surgical diseases is an integral part of modern surgical care. Rigid endoscopy (e.g. bronchoscopy, esophagoscopy, choledochoscopy, cystoscopy, arthroscopy) has long been the purview of the surgical specialist. Flexible fiberoptic technology, which now allows simpler and safer endoscopic intervention, has greatly expanded our diagnostic and therapeutic options. These improved endoscopic techniques have been rapidly incorporated into the training programs and surgical practices of those specialties (e.g. orthopedics, urology) whose medical colleagues do not use rigid endoscopes [1]. Unfortunately, the introduction of flexible endoscopy into those surgical practices (e.g. general surgery, thoracic surgery) whose medical counterparts also practiced rigid endoscopy (e.g. gastroenterology, pulmonary medicine) was delayed by competition for patients and training opportunities, economic and political conflicts, as well as an apparent or perceived lack of surgical interest [1, 2]. Endoscopy of the gastrointestinal tract has particularly engendered significant controversy and interspecialty rivalry. The treatment of gastrointestinal disease has been dramatically influenced by fiberoptic endoscopic technology: Premalignant or early malignant lesions of the esophagus, stomach, duodenum, or colon can be discovered and proven histologically. Critical surgical decisions can be greatly facilitated by endoscopic evaluation of esophagitis, by localization of gastric lesions in close proximity to the cardia, and by intraoperative endoscopy in patients with occult gastrointestinal bleeding [3]. Assessment of gastrointestinal tumor resectability may prove to be enhanced with endoscopic ultrasonography [4]. Variceal sclerotherapy, percutaneous endoscopic gastrostomy, stricture dilatation, foreign body removal, endoscopic sphincterotomy, biliary endoprosthesis insertion, colonic polypectomy, and most recently, laparoscopic cholecystectomy, are but a few examples of how endoscopic technology has altered our therapeutic approach to gastrointestinal disease. Postoperative surveillance is of obvious import in follow-up of colonic neoplasia. Thus, endoscopic procedures are essential to the proper care - - be it medical or surgical - - of patients afflicted with gastrointestinal disorders
and are, therefore, a critical component in the armamentarium of the surgical practitioner addressing gastrointestinal ailments. The surgical endoscopist should teach endoscopy Recognizing the import of endoscopy, the American Board of Surgery specifies that "the General Surgeon must be capable of employing endoscopic techniques, particularly proctosigmoidoscopy and operative choledochoscopy, and must have experience with a variety of other endoscopic techniques such as laryngoscopy, bronchoscopy, esophagogastroduodenoscopy, colonoscopy, and peritoneoscopy [5]". Thus, surgical residency program directors have an obligation to provide endoscopic training for their residents. This obligation is underscored by the fact that general surgeons are more likely to practice in small, nonmetropolitan areas than are medical specialists [1, 6]. The general surgeon, therefore, may be the only available trained endoscopist in the area [1, 6]. Endoscopic training programs can be of variable structure. One design creates rotations for surgical residents on gastroenterology services [6]. While acceptable within some training programs, such an arrangement may inadequately support surgical needs [7], creating rotations where surgical residents are regarded as "second class citizens" [8] and/or where gastroenterology instructors are unfamiliar with the surgical considerations germane to certain endoscopic procedures [1, 8]. For these reasons, many programs have opted to create a separate surgical endoscopy service with a designated surgical endoscopic instructor [1, 9]. Formal surgical endoscopic training can be obtained through an integrated experience, a separate endoscopic rotation, a fellowship following residency, or an individually arranged preceptorship [I]. Although each option has relative advantages and disadvantages [1], the exact nature of the endoscopic training program must depend on the circumstances involved. Surgical residents, whose daily routine requires manual dexterity and handling of tissues, rapidly develop safe endoscopic skills [7]. Further, the typical university program offers sufficient clinical material to provide training in surgical endoscopy [10]. Endoscopy is rapidly integrated into surgical resi-
dents' patient care and thus is a vital component of their surgical training. With the expansion of endoscopic and laparoscopic interventions, it is particularly important that surgical training programs aggressively integrate this educational obligation. The surgical endoscopist should participate in endoscopic research The excitement and explosive interest generated by laparoscopic cholecystectomy demonstrates how surgical endoscopic research has expanded our therapeutic options while improving patient care. The American Board of Surgery indicates that "it is desirable that the General Surgeon have opportunity, whenever possible, to gain some knowledge and experience of evolving technological methods, e.g. laser applications, lithotripsy, and endoscopic operations" [5]. Thus, surgical endoscopists have an obligation not only to our patients, but also to our pupils to continue endoscopic research. We must strive to remain at the forefront of ongoing technological innovation. Aaron S. Fink
References 1. Dent TL, Kukora JS, Leibrandt TJ (1989) Teaching surgical endoscopy of the gastrointestinal tract. World J Surg 13: 2022O5 2. Marks G (1989) The surgeon as endoscopist, Surg Clin North Am 69:1123-1127 3. Bowden TA, Hoods VH, Mansberger AR (1980) Intraoperative gastrointestinal endoscopy. Ann Surg 191:680-687 4. Tio TL, Tytgat GNJ, Cikot RJLM, et al. (1990) Ampullopancreatic carcinoma: preoperative TNM classification with endosonography. Radiology 175:455-461 5. American Board of Surgery, Inc.: Booklet of Information. Philadelphia, PA; July 1990-June, 1991 6. Schwesinger WH, Levine BA (1984) Endoscopy training in a general surgery program. Results of a survey. Arch Surg (1984) 119:384-386 7. Starling JR, Morrissey JF (1982) One solution to the dilemma of endoscopic requirements for general surgical residents. Surg Gynecol Obstet 155:65-66 8. Max MH, Polk HC, Jr (1982) Perceived needs for gastrointestinal endoscopic training in surgical residencies. Am J Surg 143: 150-154 9. Ponsky J (1988) The incorporation of endoscopic training into a surgical residency. Newsletter of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Spring, 1988; p. 2 10. Smale BF, Reber HA, Terry BE, et al. (1983) The creation of a surgical endoscopy training program - - Is there sufficient clinical material? Surgery 94:180-185
