The interface between gastroenterology and surgery — time for restructuring

Digestive medicine has changed progressively and dramatically over the last few decades. Gastroenterologists practicing today can remember a world without endoscopes or scans, when ulcers were caused by stress, when there was only one type of hepatitis, no transplantation, and when a two-year fellowship was sufficient, even with time in basic science. The  major players on the digestive stage were easy to distinguish: gastroenterologists wore suits and offered advice, surgeons wore scrubs and made large incisions, and radiologists wore lead aprons and looked at shadows. Many things have changed since that time, but the most intrusive has been the juggernaut of flexible endoscopy. Diagnostic instruments developed in the 1960s became the platforms for powerful therapeutic tools in the following decade. Procedures like esophageal dilation, hemostasis, foreign body extraction, polypectomy, biliary stenting and stone extraction, carried gastroenterologists deep into “surgical” territory. This happened with relatively little resistance from surgical colleagues, since most of the new endoscopic procedures (e.g., colonoscopic polypectomy) were obviously preferable to a traditional open surgical approach. Interestingly, many of these advances were actually first described by surgical endoscopists. However, the preoccupation with endoscopy by trainees and practitioners was not universally welcomed by the leaders of academic gastroenterology, leading to significant tension between the so-called “cognitive” and the “technical” wings. Make sure to consider the whole patient, not just the hole in the patient. This concern is still pertinent today, when most community gastroenterologists are consumed by colonoscopy. It is also somewhat ironic that most academic divisions of gastroenterology are now dependent on the fees from endoscopy.

But, it is the interface with surgery that concerns me now. Gastroenterologists are becoming progressively more invasive, whilst much of surgery has become less so. The actors on the digestive stage now look very similar: minimally invasive surgeons, interventional gastroenterologists and radiologists  all wear scrubs, gowns and gloves, and work with complex instruments passed through small holes in their patients, guided by images on endoscopic and radiologic monitors. However, this convergence of technological approaches has not been accompanied by any real changes in the organization of medical training or practice.

A plea for restructuring was made more than one year ago, and some university health systems have set up multidisciplinary centers to foster collaboration, and indeed to provide a platform for the clinical research and teaching, which will improve patient care in the future. Their development has been slow and painful, since they are largely resisted by the chairs of traditional departments, for obvious reasons. Without a structure for collaboration, the tensions at the interface between the gastroenterology and surgery are likely to increase over the next decade. Gastroenterologists will be doing less diagnostic endoscopy. This will result from better selection for screening  and surveillance using genetic markers of risk and disease, new diagnostic approaches (such as CT colonography and capsule colonoscopy) and the increasing use of endoscopy by other practitioners, including non-physicians. Future clinical gastroenterologists will have to focus increasingly elsewhere. Some will return to a consultation role, and some will specialize in other areas (such as motility, nutrition and cancer care). Others will focus on therapeutic endoscopy, using refinements of current procedures, and new techniques, which will further encroach on surgical turf. Endoscopists have begun to perform fundoplication, and there is much interest in developing endoscopic approaches to obesity. Widespread mucosal resection is used increasingly for treatment of neoplasia in the esophagus, stomach and colon. The most dramatic change is that a few pioneers have literally jumped “out of the box,” escaping the constraints of the lumen by driving their endoscopes through the gastric wall into a whole new world — the abdominal cavity.

So-called Natural Orifice Transluminal Endoscopic Surgery (NOTES) has allowed appendectomy, tubal ligation, gastroenterostomy and even cholecystectomy. Most of these procedures have been performed in animal models, but human experimentation is in progress. The mouth is not the only route; other endoscopists have approached the peritoneum through the colon and the vagina. These aggressive developments at the interface between gastroenterology and surgery raise important issues. Should all of these new flexible endoscopic procedures be done by surgeons, or are they fair game for a few enthusiastic (and brave) gastroenterologists? Must it generate into a sterile turf battle? Similar issues confront other disciplines — not least invasive cardiology which also straddles medicine, surgery and radiology. Breakthrough technologies must eventually force the elimination of artificial barriers to excellence and the development of enabling infrastructures. There is much collaboration at the individual level, and the agenda is being driven by joint medico-surgical research.

It is encouraging that a recent major conference on NOTES was organized between the American Society for Gastrointestinal Endoscopy and the Society for American Gastrointestinal Endoscopic Surgeons, and a joint position paper was published by a steering group representing the two societies. As clinicians, it is not enough for us to strive for individual excellence; it is our responsibility also to make sure that there are appropriate mechanisms for training and delivery throughout our communities, and for the next generation. The centuries-old distinction between internists and surgeons is less and less relevant and will stifle innovation and progress. Multidisciplinary digestive disease centers can foster mutual respect and collaboration, but we need to go further and develop a specific new training path toward a career in “digestive intervention”, embracing the best of both worlds. There are tremendous challenges in realizing this dream, not least in licensing and credentialing, but they must be overcome — we owe that to our patients. Who knows what will happen when the tectonic plates begin to shift? The logical extension of these concepts is that digestive centers will morph eventually into a full-blown academic ‘Departments of Digestive Science’.