Christopher DiMaio, MD, and James F. Marion, MD, discuss the development of advanced therapeutic endoscopic procedures that can provide an alternative to surgery for gastrointestinal conditions. Dr. DiMaio provides an overview of the history of endoscopy—including diagnostic and minimally invasive procedures. He provides examples of new techniques to treat complications from inflammatory bowel disease including strictures, fistulas, and precancerous lesions. He also provides a look at new techniques on the horizon.
Good afternoon. This is Dr James Marry in Broadcasting Live on tape from the Susan and Leonard Feinstein Inflammatory Bowel Disease Center and Mount Sinai Hospital in New York City. And today we have a very special and talented guest joining us today. This is Doctor Chris de Meo. He's an especially it professor of medicine here at the Icahn School of Medicine. And he is the director of therapeutic endoscopy here at Mount Sinai Hospital. I could list Chris's interests in therapeutic endoscopy, but I want to summarize to say that when I started here in the mid nineties, therapeutic endoscopy consisted of our trying to do as much as we could with snares. And that was really just about it. Chris comes in and builds this absolutely phenomenal therapeutic endoscopy presence here on campus and has greatly expanded our abilities in IBD and outside of IBD to better treat our patients and help them avoid surgery. Good morning, Chris, or good afternoon. Good afternoon, Jim. How are you? I'm well and welcome. It is such a pleasure to have you join us for this. And I know that, uh, you have much to tell us, but I want to just start with the most fundamental question for you. And that is what is advanced. Therapeutic industrial. Well, that's a great first question to start with. First of all, let me thank you for having me and hosting this. It's an honor to be part of your program here and a Z. You know, we all work very closely here in the division and with the IBD Center. So it's Ah, it's great to collaborate and yet another way with educating our viewers out here today. So you kind of hit the nail on the head. Advanced therapeutic endoscopy, uh, really involves the use of endoscopic procedures beyond standard diagnostic upper endoscopy and beyond standard diagnostic colonoscopy with removal of let's say, small polyps. Um and you hit the nail on the head earlier in that this this field really began. The advent of it was based around two things. One was the removal, the endoscopic removal of large colon polyps and the other was performing endoscopic procedures in the bile duct and the pancreas with a procedure called E R. C. P. And both of those things occurred started back in the seventies on over the over about 30 to 40 years after that. There's been an absolute explosion in our capabilities, uh, to diagnose and treat very complicated diseases that typically would require surgical intervention. Right? So this is sort of like basically taking an insider's approach to what had typically been, uh, rather violent, brutal, invasive surgery, right? Somewhat, yes, our one of our main goals when we see a patient is to try and come up with a creative way of either making a diagnosis or performing a therapy without the need for surgery, right. So give our viewers some examples of some conditions that sort of, you know, you spend a fair amount of your time on. So broadly speaking, the field, a zay said in its early stages, revolved around diseases of the pancreas and bile ducts, so conditions such as bile, duct stones, gall stones, pancreatitis, inflammation of the pancreas. As our capabilities developed, we have the ability to diagnose and stage cancerous and pre cancerous lesions of the G I tract lesions in the esophagus, stomach, the intestine and the colon, and in many cases were not able to were not only able to just diagnosed them or stage them, but we may be able to remove them and respect them. Obviously, with all these procedures, there is a risk or with any With many of these conditions, there's a risk of gastrointestinal bleeding. So the management of complicated G I bleeding also falls in our realm on. Then again, as the medicine field in surgical fields have expanded, we're seeing new problems, uh, such as development of strictures. Maybe after radiation therapy. Maybe after an operation, a colon operation, somebody gets a nasty Matic stricture or a leak or official uh, eso we're now we're now called upon to help manage some of these unique complications, and we're even expanding our role. You know, there's a whole new field of endoscopic treatment of obesity, primary treatment of obesity, where we have devices and techniques where we can help patients lose weight. Uh, for patients who may not have been traditionally been a surgical candidate or who may not want something as large as a as a surgical bypass, there's endoscopic ways of dealing with this and even motility disorders of the esophagus and the stomach, where, you know, again we can mimic what surgeons do. But in a minimally invasive platform. So, Chris, when I have a patient with I b d. You know, there are many areas of overlap where I interact either with you or with your colleagues. Dr. Qanta, Doctor Nakoula Dr Kim. Uh, and it's, uh it's always a joy one, because I love seeing you guys that I wish I saw more of you Now that we're all sort of zooming all the time. Um, but what are some of the conditions? If you could go over some of the conditions that are particular IBD that are IBD, patients may find themselves in your office or in your endoscopy room. Yeah, um, eso just also give a plug that we are a team on. We operate in a team based approach, a multi disciplinary approach. It's rare that we make decisions unilaterally. We always air interacting with our colleagues and G I in surgery and radiology and pathology s Oh, this is truly team based medicine, and it's really personalized medicine for each. Each patient has an individual specific problem and they may require different solutions. So I would like to get that out there that we do operate that way. But when it comes to IBD patients. You know the thing that comes to mind mostly are diseases of the small intestine and the colon. Eso. As an example, we know that many patients with IBD are at risk for colon cancer, and they these cancers may develop as a pre cancerous lesions or dysplasia. The tried and true method of dealing with dysplasia in the colon is to do surgery too often to remove the colon. But now that we're learning more about the natural history on, we have the tools and techniques we can safely remove these this plastic regions in an outpatient setting. You know a 20 to 30 minute procedure patient goes home and, you know, hopefully avoids massive surgery. So that's that's one riel example where advanced industry plays a role. Another example is patients with inflammatory bowel disease typically developed strictures, and these could be in the small intestine or the colon on there could be very difficult to deal with. They could be, you know, life altering very symptomatic. But again, we have minimally invasive ways of going in there, and using a balloon to stretch them open in some cases will leave a temporary stent to sort of just continuously expand that stricture. We can leave that in for several months and then pull it out. And again with the hope that this relieves their symptoms and perhaps avoid surgery. We do have creative ways of getting down into the small intestine. Uh, many. I'm sure many people are aware of the video capsule, which is a small pill that could be swallowed. Thio visualized the entire small intestine system. Uh, but, you know, when that first came out, there wasn't a great way to actually access the small bowel or reach those lesions. But now we have, ah, device called the balloon. Enter a scope which allows the user to go from the mouth all the way down into the genome and the ilium on either take biopsies of suspicious lesions. Deal with G I bleeding. So again, in an IBD world, the small bowel in the column is a lot of applications for us, as I mentioned earlier with the advent and explosion of surgery, Uh, even in the best of surgical hands, there's always gonna be, you know, a risk of of complications or adverse events leaking fistulas strictures. So again, we're often called on to support our surgical colleagues in managing these again, it may be a dilation of a stricture. If somebody has a leak, it may be closing that leak, maybe with a clip, maybe with endoscopic suit during, maybe with a stent. Um, if they have a large collection and abscess, there are ways that we can go in there and drain thes abscesses, and then I think the other area that people probably don't think much about in the IBD population. But there are unique liver and pancreas diseases that IBD can be associated with. So the most common one is primary sclerosing cholangitis, which is a inflammatory condition of the bile ducts, which can lead, which can lead to blockages and strictures and actually is a risk factor for cancer. So it's not unusual that we are called upon to evaluate a patient who may have a symptomatic obstruction of the bile duct. Perhaps they're jaundice or they're itchy on. We can use our tools not only to just take simple biopsies. We actually have miniature cameras that can go down the down, the main scope up into the bile duct, and it's like doing a colonoscopy within the bile duct. It's really amazing, and we could take very targeted biopsies. We can rule out a cancer or say, you know, this is a benign stricture we can place stents on then and then another, you know, related to one of my interest in pancreatic disease. There's this increasing recognition of a condition called autoimmune pancreatitis, which, uh, one of the diagnostic features of a subtype of this condition is associate is having an inflammatory bowel disease. And in my practice, I've seen a number of patients that we've done pancreatic biopsies to diagnose this condition of auto mean pancreatitis. And in my experience, a lot of these patients sort of have this lingering pancreatitis that doesn't seem to go away with standard therapy. They sort of linger on for weeks and months. And you know, now we're recognizing this as a as a nen titty unique thio IBD patients. And so again we have the capabilities of taking a biopsy and making a diagnosis. That's fantastic, Chris. I mean, it's really amazing to me how far you've extended the reach of our scopes showing these really grand procedures in very small spaces on. I know whenever I have the opportunity to step into your room and just sort of watch you do your your plumbing. Uh, it's, uh, really. It's a sight to be seen, and I really, really love it. Um, so, Chris, we've come a long ways. New tools coming out all the time, a continued push for further innovation. I know that's really our middle name here at Mount Sinai. What's next? What do you see coming up next, particularly in I B D in Advanced Therapeutics or in any area of advanced therapeutic and Oscar paper? Well, it's it's interesting, just, you know, to go back to the original history of this field. It started mostly with E. R. C. P, or endoscopy of the bile, duct and pancreas on and around the same time, the development of removal of large colon polyps. Now, uh, in the year 2020 it seems that every month we're having a new device at our in our hands a new technique, a new tool that is being developed to deal creatively deal with these with the vast array of of of conditions, medical conditions. So I think, again targeted towards the IBD population. I think our ability to remove pre cancerous and cancerous lesions safely and effectively. Will Onley continue to get better? Um, people are really pushing the bounds and the limits. You know, we're not taking out, you know, polyps that air just the size of your fingernail. We're taking out polyps that you know are several centimeters in size, maybe over going multiple folds, where I think the average person would look at that and say, Wow, that that needs to go to surgery But again, I think the tools and techniques are quickly being developed that that will be a reality, that that will be the first line treatment for many patients. With these conditions, I think the other the other area where there's a need for improvement is management of strictures. Um, with Crohn's disease, thes illegal strictures or Kalanick strictures can really be a burden on patients. Quality of life there in and out of the Endo unit. They're in and out of the hospital with obstructions, and we know that performing these balloon dilation is really just sort of a temporary relief. It's a Band Aid. It's not a good long term solution, but we now have and it's starting to make their way from Europe. Biodegradable stents, which are designed to be placed in a benign condition, uh, dilate a stricture. And then these biodegradable stents just melt away over the course of weeks and months and again, it saves the patient from having to undergo another procedure to remove that step. Similarly, another big issue for IBD patients are fistulas, Um, whether they are primary Fischel is due to Crohn's disease or a post operative complication. Uh, and and there are many who are developing techniques where we're using incision all therapy. So instead of trying to close the leaking area or the fish allies area, let's help it drain even better. Let's let's use our endoscopic dissecting tools to sort of make it bigger. Let things drain better, and perhaps that will let these fistulas and the scientist tracks. He'll and there's even been some very interesting work, which which I think, is going to make a comeback where folks are starting to use endoscopy to inject biologics and immuno modulators directly into areas of strictures. And perhaps Fischel is to really get a high dosage, uh, concentration of the of the drug in the area where it's needed most s. So I think those air very, very exciting possibilities, I will say. And this is literally hot off the presses and I can't say too much about it. But some of our surgeons air working right now with European groups and the FDA with trying Thio to bring toe thio the field a device which is placed endoscopic Lee immediately after colon surgery with the idea that it will eliminate the possibility of a nasty Matic leaks and fistulas. And it has the ability to revolutionize uh, colon cancer are colon surgery and intestinal surgery because now it gives patients the opportunity to have a one step operation, whereas traditionally they may have had a two step surgery. Eso these air things that air rapidly coming. I mean, literally, This is something that came through my inbox, Uh, over the weekend. Eso it's really it's really amazing how quickly things were going and then and then. The one other area, which may have some role for inflammatory bowel disease patients but certainly has a broad applicability, is that will soon be able to provide endoscopic therapy to cancers. Um, example is pancreas cancer traditionally aggressive, very difficult to treat cancer, often refractory to things like chemotherapy. Many patients aren't surgical candidates, but using our basic endoscopic equipment basic endoscopic needles, we can guide needles directly into tumors and deliver drugs we can deliver and a blade of energy and again use. This is part of a team based approach to augment chemotherapy. Or perhaps downstage, a patient may not have been a surgical candidate to now undergo surgery, So we're really just limited by our own creativity. And it's amazing, truly amazing. What is going on? It's a minimally invasive revolution. Uh, that is occurring right before us. Thes days. Yeah, no, Chris. And it's wonderful to hear that many of these truly vexing problems are, You know, we're all looking at together and sort of bouncing off potential solutions off one another and really hoping for some innovation for these tougher problems. And then I think I'm sorry, I was just gonna say, and I think you hit the nail on the head. Collaboration is the key. I often joke to my patients that I don't know how to spell IBD, so I can't. I often cannot comment on how what the what the natural history of their diseases there, Crohn's disease or also of colitis? Or, you know, how long will it take for a biologic to kick in? But that's where our daily communication with each other in our respective teams, you know, we work hand in hand in trying to help our patients. And, uh, I think it's a very special thing. I think that's what makes Mount Sinai and outstanding, outstanding institution. And it has this legacy of excellence in the field of gastroenterology, and and I am humbled to be a small piece of that eso, you know, I think again we're still going to keep pushing the envelope. And working together is a key part of that. And I really look forward to that, Chris, and you are no small piece of it. I think I love bouncing ideas off you. And what can I say? Your pleasure to work with, um and, uh, way meat everyday practically in that cauldron of innovation over in the end of unit e o exactly. CEO. So, Chris, I want to thank you again for joining us. Um and I hope to have you back here at some point soon. again to talk about whatever you'd like. I always enjoy hearing you think out loud and, uh uh, so again. Thank you. Thank you. Have a great day. Yes. This is Dr James. Marry in Once again with the third Thursday Facebook like broadcast from the Susan lettered Feinstein Inflammatory Bowel Disease Center here in New York City. Uh, forward to seeing you again next month.