Endoscopic Procedures

A specialized flexible endoscopic instrument is carefully negotiated through the mouth to closely examine the oesophagus, stomach, and duodenum. Any evidence of upper gastrointestinal pathology is closely assessed using high-definition white light and other modalities such as narrow band imaging. Appropriate images are taken, and biopsies are sent for histology as indicated. Upper endoscopy is a highly operator dependent procedure.

A specialized flexible colonoscope is carefully negotiated through the anus to closely examine the colon. This is slowly removed to allow optimal examination of the colonic lining to exclude any colonic polyps or other colonic pathology. Any evidence of colonic pathology is closely assessed using high-definition white light and other modalities such as narrow band imaging. Appropriate images are taken, and biopsies are sent for histology as indicated. Most colonic polyps are less than 10mm in diameter and can be removed. Larger polyps may require a further dedicated session.

High quality colonoscopy is a function of good bowel preparation and careful colonoscopic examination by an experienced operator. Colonoscopy is a highly operator dependent procedure.

Most colonic polyps are less than 10mm in diameter and can be removed at the time of a standard diagnostic colonoscopy. Multiple colonic polyps or larger lesions (particularly those greater than 20mm in diameter) may require a further dedicated session because of the time and technical approach required. Large colonic polypectomy also has a different risk profile which needs to be considered. It is a minimally invasive approach for removing large colonic lesions, avoiding significant colonic surgery, and therefore maintaining normal colonic anatomy.

Most general gastroenterologists do not perform large colonic polypectomy hence the need to refer to a specialist interventional gastroenterologist. Large colonic polypectomy is essentially a minimally invasive endoscopic surgical procedure requiring a high level of expertise to maximize the likelihood of complete colonic polyp removal and minimize the likelihood of complications.

Prof Hourigan is a national leader in the endoscopic management of large colonic polyps. He contributes to multi-centre, collaborative Australian research, which focuses on the evidence based management of large colonic polyps; these studies have formed the basis of widely accepted international large colonic polyp management guidelines.

High quality colonoscopy is a function of good bowel preparation and careful colonoscopic examination by an experienced operator. Colonoscopy is a highly operator dependent procedure.

Since 2005 there has been a paradigm shift in the management of Barrett’s dysplasia and early oesophageal malignancy. Previously such disease would have required significant surgery with oesophagectomy. Fortunately, there are now well established minimally invasive endoscopic procedures, performed through the mouth, which can clear the pathology by removing the diseased lining or mucosa through either an endoscopic resection (cutting) device and/or an endoscopic thermal (heat) ablation device. The latter is otherwise known as radiofrequency ablation. Usually, serial treatments are required for complete disease eradication. The major benefit is that normal oesophageal anatomy and function is preserved.

Prof Hourigan pioneered oesophageal endoscopic resection in Queensland. He has over 20 years’ experience in the endoscopic management of Barrett’s dysplasia and early oesophageal malignancy.

Since 2010, there has been a paradigm shift in the management of achalasia and related oesophageal motility disorders. Previously, traditional surgery (Heller’s myotomy) was the only option. Now there are several minimally invasive endoscopic options performed through the mouth.

Peroral endoscopic myotomy (POEM) is now widely accepted as the definitive approach for these disorders. There are multiple endoscopic options other than POEM which can be considered, including Botox injection and pneumatic balloon dilatation.

Traditional surgery (Heller’s myotomy) is also still a viable option after POEM, if ever required. POEM performed after a Heller’s myotomy is still possible but can be technically very difficult. Therefore, POEM is the best initial myotomy approach, if indicated.

POEM requires a general anaesthetic. A 20mm longitudinal entry incision is made in the oesophageal lining (mucosa). A careful endoscopic dissection is performed to the deep oesophageal muscle layer and an approximately 15cm long tunnel is then performed over the lower oesophagus and through the tight gastro-oesophageal junction to the upper stomach region (still beneath the lining), closely following the deep muscle layer. A longitudinal cut of the tight and thickened muscle is then carefully performed. Finally, the initial 20mm longitudinal entry incision of the oesophageal lining is closed with temporary clips, which eventually fall off spontaneously after several weeks.

Prof Hourigan pioneered Peroral Endoscopic Myotomy (POEM) in Queensland in 2015 for the minimally invasive management of achalasia. He is one of the most experienced at performing Peroral Endoscopic Myotomy (POEM) in Australia.

A specialized side viewing duodenal endoscope (duodenoscope) is carefully negotiated through the mouth to the duodenum, which is the small bowel after the stomach where the bile and pancreatic ducts allow passage of bile and pancreatic secretions. These ducts converge at a small nipple like structure in the duodenum called the major ampulla, which also serves as an endoscopic access site. A fine catheter and guidewire can be gently placed at the major ampulla to access both ducts as required. The procedure is performed under x-ray guidance. Most ERCP procedures are primarily performed to access the bile duct to facilitate stone removal or placement of a stent to unblock any obstruction. Selective pancreatic duct procedures can also be performed, if required. Biopsies or cell brushings can be performed to assist with the diagnosis of any bile duct or pancreatic duct pathology.

A mini endoscope (cholangioscope) can also be passed through the duodenoscope directly into either the bile duct or pancreatic duct to facilitate the management of more complex conditions. These would include large biliary or pancreatic stones and obstructing tumours.

Rarely the major ampulla develops pathology which can be removed with a combination of endoscopic resection techniques and ERCP. This procedure is called endoscopic ampullectomy.

Prof Hourigan is highly experienced at ERCP. He is one of the most experienced at performing and training complex ERCP in Australia.

A specialized endoscope with an incorporated ultrasound probe at the tip allows high quality imaging and assessment of the gastrointestinal tract, pancreas, and bile duct. It complements any prior imaging including a CT scan, an MRI, and a standard abdominal ultrasound.

Specific lesions can be assessed and targeted with a very fine needle to obtain diagnostic tissue sampling.

Other early malignant lesions of the gastrointestinal are amenable to endoscopic removal if they are limited to the lining (mucosa). In many cases, there is benefit in removing these lesions within a single resection specimen (en bloc). This involves a complex endoscopic procedure called endoscopic submucosal dissection (ESD). This is a minimally invasive endoscopic procedure with curative intent and the aim of avoiding more extensive surgery and maintaining normal gastrointestinal anatomy.

A small PillCam capsule device is usually easily swallowed with a glass of water under the supervision of a technician to allow video assessment of the small bowel. A recorder belt is worn throughout the day. This video allows assessment of the entire small bowel and to exclude any potential small bowel pathology. It is commonly performed to assess for potential gastrointestinal bleeding as a cause of iron deficiency anaemia. Considering the length of the small bowel and the several hours of video that need to be reviewed, the final report can take up to 2-3 weeks to be completed depending on the clinical urgency.