Introduction

Colonoscopy is the reference method for the diagnosis and treatment of colorectal disease, since it offers the highest sensitivity and specificity^1,2.

The method is safe and effective when used by trained professionals, with a low incidence of complications and excellent tolerance for the patient. The incidence of complications is low, between 0.1 and 3%; large bowel perforations (0-5-3%) and bleeding (0.2-3%) are the most common evens^1-3. Among diagnostic colonoscopies, the incidence of complications is between 0.016 and 8%, while complications in therapeutic procedures range form 0.02% to 8%^4,5. About half (45-60%) of these events are detected by the operator during the procedure. In those cases in which the complication is not suspected or the diagnosis is delayed, perforation may lead to peritonitis, increasing morbidity and mortality up to 50%. It generally ranges from 5 to 25%, depending on factors such as delay in diagnosis, clinical presentation, and type and time of treatment^1,3,4.

Few national studies have evaluated colonoscopies performed by surgeons and their results, although endoscopy and colonoscopy have recently been on the agenda of different general surgery congresses^4,5. There is no agreement about its implementation among surgeons or about the postgraduate training in general or colorectal surgery.

The primary endpoint of this study was to analyze the outcomes of colonoscopies performed by colorectal surgeons in terms of complications and their resolution. The secondary endpoint was to compare the results between a university hospital and different centers nationwide staffed with colorectal surgeons who received formal training during a residency program in a surgical subspecialty.

Material and methods

A prospective, multi-center and consecutive study was conducted among selected centers nationwide with expertise in colonoscopy performed by colorectal surgeons. The provincial centers selected were those with surgeons trained in the procedure during their residency in a surgical subspecialty.

The results were analyzed by a reference center that has a residency program in colorectal surgery and has a formal training program in colonoscopy.

The participating centers were:

▪▪Tucumán: Sector Coloproctología, Sanatorio Modelo

▪▪Salta: Centro Integral de Coloprotología CIDEC

▪▪Formosa: Clínica Vrsalovic y Centro de Medicina Ambulatoria

▪▪Neuquén: Centro de Especialidades Médicas

▪▪Córdoba: Unidad Digestiva Baistrocchi

▪▪Buenos Aires: Servicio de Coloproctología, Hospital Británico

Hospital Británico de Buenos Aires was the reference center and the provincial centers were those represented by Córdoba, Salta, Neuquén, Formosa and Tucumán.

All the colonoscopies performed between January 2011 and January 2016 were prospectively recorded in a database. The following variables were considered: number of procedures, age, sex, type of endoscopy (diagnostic or therapeutic), incidence and type of complications (categorized in general or systemic complications and procedure-related complications), anatomic area of the complication, treatment implemented (medical, endoscopic or surgical treatment), type of surgery (ostomy, repair or resection) and associated morbidity and mortality.

Results

A total of 24,907 colonoscopies were performed by surgeons in the six participating centers during the study period; 17,202 (69%) were performed in the provincial centers and 7705 (31%) in the city of Buenos Aires. The population was made up of 13.324 (53.4%) women and 11.686 (46.6%) men.

Mean age was 50 years (15-91); 7348 procedures (29,5%) were conducted in patients < 50 years and 17,779 (70.5%) in > 50 years. Completion rate was 94.7% (90-98%). Time to completion was 25 minutes (range 10-15). Ninety-seven percent (94-99%) of the colonoscopies were outpatient procedures.

In 17,283 (69%) of the cases colonoscopies were diagnostic procedures and 7624 (31%) were therapeutic and included poplypectomies, dilation of stenosis, mucosectomies or treatment of vascular ectasia. The number and type of procedures performed in each group are shown in Table 1.

A total 43 (0.17%) complications were recorded: eight (0.03%) systemic or general events and 35 (0.14%) procedure-related complications (19 perforations, eight bleeding events, five post-polypectomy syndromes) and three were related with the technique. The incidence of complications after diagnostic colonoscopies was 0.14% (24/17,293) and was 0.25% (19/7614) after therapeutic procedures; 63.6% (7/11) occurred in women and all after outpatient colonoscopies. There were deaths in the series (Table 2).

There was a significantly higher incidence of global complications and procedure-related complications in therapeutic procedures versus diagnostic procedures but the incidence of general or systemic complications was similar in both groups (Table 3).

Discussion

The rate of complications after colonoscopy is about 1%, with 0.2-0.8% of perforations and 0.4- 1% of bleeding events^1-5. Other authors reported an incidence of perforations of 0.19% and a mortality rate of 0.019%^2,9-12. Female sex is an independent risk factor for perforation and sigmoid colon is the most common site affected (65%)^2-4. These data are consistent with our experience, in which the left colon and rectum were the most affected segments, with a slightly greater involvement for the female sex; perforation was the most common complication in this series.

Other complications have been described, as hemoperitoneum, hematoma of the mesocolon, splenic injury, subcutaneous emphysema, pneumothorax, aneurysm rupture, pain due to severe distension and bacteremia, anesthetic and cardiovascular disorders, and those attributed to bowel preparation^9,10,13-15. In this series, we reported perforation, bleeding events, post- polypectomy syndrome, technical events and systemic or general complications, which are consistent with the results of a previous publication of our group¹¹.

The literature confirms that the incidence of perforations is higher in diagnostic procedures, while bleeding events are more common after therapeutic colonoscopies^3,5,9-11. In this analysis, the global incidence of complications was similar for both procedures; however, specific complications were higher in therapeutic endoscopies. In this series, the incidence of perforations was twice as high in therapeutic procedures and bleeding events only occurred in this type of procedure.

Medical treatment or expectant management of perforations ensures a high success rate in the literature^1,3,5,9. This should be the initial strategy in case of adequate local and general conditions and if the endoscopist’s impression is favourable^13-15. The response to conservative treatment was excellent in all the cases where it was implemented.

Treatment of colonic perforation after colonoscopy depends on many factors as polypectomy, the characteristics of the lesion, the presence of previous disease, the type of presentation, the time of diagnosis and the time between perforation and surgery^10-12. In the present analysis, the diagnosis and resolution of complications were made early.

Endoscopic treatment of perforations is limited to highly selected cases: those detected during the procedure or within 4 hours, perforation size < 1 cm and an experienced endoscopist. Clips have been used since 1997 with a success rate of 59 to 100%^5-15. Larger perforations can be closed with clips combined with endoloops. This strategy was used in one patient in this series and was considered a noninvasive strategy as in previous publications¹⁶.

Colonic resection with primary anastomosis was the most common type of surgery, solving both the complication and the underlying condition, followed by colonic repair. Resection with anastomosis is feasible thanks to the previous mechanical bowel preparation. According to the most recent guidelines for the treatment of colonic perforation, the concepts of early resection are those reproduced in this series, as well as the surgeon’s experience in indicating colonic repair, wedge resection, or segmental resection with or without anastomosis. Colonic resection is indicated for large perforations, those with edges that are not suitable for colonic repair, and in case of injury to the mesocolon or associated conditions¹⁶.

The incidence of ostomies as a complication of colonoscopy occurs in 10% of cases because of delayed implementation or use of other approaches, such as persistent medical or endoscopic treatment instead of early surgery^2,10,16. In our series, we performed two ostomies; one to protect an anastomosis and another as single treatment.

There was no morbidity or mortality after the complication was resolved; these results are attributed to the correct choice of surgical strategy, patient selection and therapeutic resolution by the same team in charge of endoscopy.

The laparoscopic approach is an excellent option to treat these complications. According to Laporte et al., morbidity is lower and length of hospital stay is shorter than those of a similar group treated with a conventional approach¹⁷. A similar experience was reported by some authors who treated colonoscopy-related complications with laparoscopic surgery^3,5,11.

The global incidence of bleeding events is < 1% and increases to 2.7% after polypectomy and 12% after mucosectomy^2-4. Bleeding after polypectomy can be treated with a conservative approach or not, such as repeating the endoscopy, placement of endoscopic clips, injection of adrenaline or argon plasma coagulation. Less than 20% require surgery⁵. In our experience, the endoscopic approach was the treatment of choice. Bleeding events were treated with a conservative approach associated with repeating the endoscopy and using endoscopic hemostasia with clips or argon plasma coagulation. Surgery was only indicated if endoscopic treatment failed.

When these results were compared with national and international publications, the incidence was very low and only occurred in therapeutic endoscopies, both in this study and in a previous series published by the same group^1,5,14.

Post-polypectomy syndrome or post-polypectomy electrocoagulation syndrome has also been reported in the national literature¹⁵. Although it is less common than perforation, its underdiagnosis may produce unexpected morbidity. In the series, the clinical suspicion associated with imaging tests provided the opportunity to successfully treating all the patients with a conservative approach.

Unlike other reports, we did not find anesthesia-related complications or mesocolic or parenchymal lesions; systemic complications did not have clinical significance. There was no morbidity associated with disinfection^{1,3,5,9,11,16,17}.

In a previous series, the incidence of complications between the treating centers and the reference center was similar. In this analysis, the results were not only confirmed, but the incidence of global and procedure-related complications. morbidity and mortality were also lower than in the previous series¹¹.

This study confirms the excellent results achieved with the training program in colonoscopy during a residency in a surgical subspecialty. All surgeons included completed their specific residency programs and their results would support our concept that training in colonoscopy should be included in the specialty from the beginning.

There is no agreement in Argentina on when and how to introduce endoscopy in general surgery training programs. For years, its implementation was not part of the usual practices of colorectal surgeons as evidenced by the Official Report “Flexible Endoscopy: A New Challenge for the Surgeon”. A “surgeon endoscopist” is a surgeon with sufficient knowledge

and technical skills to use flexible endoscopy in his/ her practice⁵. In the survey carried out by the Official Report, gastroenterologists trained surgeons in endoscopy skills in the majority of the cases, while training was provided by surgeons in only 4% of the cases⁵. Something similar occurred in a survey carried out among colorectal surgeons, which showed their lack of interest in the dissemination of the method and its inclusion in residency programs¹⁸. On the contrary, the results obtained among residents in surgery showed a positive and favorable attitude towards incorporating this procedure in their training programs¹⁹. When medical students were interviewed, they showed the same interest in incorporating information about the procedure at any level of undergraduate education¹⁹. Similar findings were reported in a survey conducted among rural and nonrural surgeons, confirming what we have concluded throughout this analysis²⁰.

Wexner highlighted that surgeons or coloproctologists needed to perform endoscopies in their patients and that training in endoscopy should be incorporated at any level during their formation²¹. FLS (Fundamentals of Laparoscopic Surgery) and FES (Fundamentals of Endoscopic Surgery) certifications are required by many associations for general surgery trainees to be eligible for board certification⁵. The Committee on Residency Programs of Asociación Argentina de Cirugía states that endoscopy training in diagnostic and therapeutic procedures must be part of the core curriculum in general surgery residency training ²².

We consider that the incorporation of this technique in the basic training in surgery or in undergraduate education could bring about the necessary shift in attitude that still needs to be achieved to return the surgeon to the place lost in the practice of flexible endoscopy, This shift should also be included in the modifications of surgeons training programs as proposed more than 30 years ago²³. An example of this change is the growing interest in publications on the matter by surgeons in the specialty^24,25.

In the analysis of the literature, we did not find any national multicenter publication, carried out by endoscopic surgeons analyzing the safety and efficacy of the procedure, There is also lack of reports about the sufficient expertise provided by training programs in colorectal surgery, and confirmed by the results obtained.

Conclusions

Colonoscopies performed by trained surgeons are safe and reproducible among different groups of surgeons. The incidence of complications after a colonoscopy is low and similar among the different group of surgeons in provincial centers and in the reference center.

We believe these results support trained surgeons to perform colonoscopies as a specialty-related procedure and to receive training in a residency program as part of an effective system of education for a surgical subspecialty.

Discussion at the session of the Argentine Academy of Surgery

Fabio Leiro: I congratulate Dr. Hugo Amarillo for the work he brings to this Academy and I thank Dr. Mario Salomón for reading it. I think that this is an extremely relevant topic, and, in my opinion, it is very important to bring these topics to the Academy, undoubtedly the most prestigious surgical setting in our environment. Although we all know that endoscopy is a method that can be performed by surgeons, it is worth discussing this matter in the Academy. Colorectal surgeons who are adequately trained in this method can perform colonoscopies once they return to their place of practice, as colonoscopy is not a specialty but a tool that colorectal surgeons must know how to manage. In 2008, we introduced a colonoscope that was a donation from a grant made by JICA in Japan to the Division of General Surgery of the Hospital Pena. In 2009, we analyzed 200 endoscopies with the department of gastroenterology, which were presented at the Society of Coloproctology; we analyzed 200 consecutive colonoscopies performed by coloproctologists from our service who had been trained and had learned the method during their training program in coloproctology, and we had quite good results at that time with 90% of complete colonoscopies, 45% were normal but more than 50% presented polypoid lesions that were treated without complications during the same procedure. It was a small study, but it already showed a few years ago that this method could be performed by well-trained surgeons. We also believe that colonoscopy should be part of the training program of residents in general surgery. We have a colonoscope available and we continue to keep it in the service and the residents in surgery in our hospital learn how to perform colonoscopies during their residency program in general surgery. So, it seems to me that this topic is of current interest and I especially congratulate Dr. Hugo Amarillo and all the co-authors of the paper.

Hugo A. Amarillo: Firstly, I would like to thank the authorities of the Academy for the possibility of reading this article, for accepting it and for helping me with my trip and the date of the reading. I would also like to thank Dr. Mario Salomón, for the possibility of reading the paper, and for the many corrections and the advice he gave to all the authors for the preparation of this paper, and also for providing me with all the numbers of his service as a collaboration for this work. I would also like to thank each of the co-authors of this paper who know the meaning of providing and sharing all the complications, which is not a minor matter, and make them available to the public so that we can share and draw conclusions.

I thank Dr. Leiro for his comments. We totally agree with all the concepts expressed, and I would particularly like to emphasize the fact that colonoscopy or flexible endoscopy are not a specialty, but rather a method that we must not lose. Today, as Dr. Salomón said, nobody would doubt that laparoscopy is part of the residency program in general surgery or in any surgical specialty, and this is the concept that one tries to convey when discussing flexible endoscopy in this Academy. I believe this strategy must be part of basic training in surgery and not only of the surgical subspecialty.

Nicolás A. Rotholtz: I also congratulate Dr. Amarillo for bringing this kind of topics to the Academy and Dr. Salomón for his presentation. I am going to address to some concepts that have already been discussed, but I think it is important that in this environment we can strengthen the idea that surgeons perform endoscopies, and when I say this I am talking not only about colorectal surgeons but also about each of the sub-specialties that have some relationship with endoscopies. Endoscopy must be one more tool for us surgeons in our subspecialty and not a specialty. At some point in our history of surgery, laparoscopy and ultrasound were mentioned as sub-specialties, but today it is difficult to say that a surgeon is focused on laparoscopy, ultrasound or endoscopy. We should keep emphasizing the concept that all these activities are additional tools. And that is why I also want to emphasize the fact that at least, and this is an absolutely personal concept, I believe that endoscopy must be performed by sub-specialists and avoid doing what has happened with the gastroenterologists who ultimately perform all types of endoscopies, transforming or attempting to transform it into a specialty. That is why I also believe that endoscopy should be presented as a tool in general surgery residency programs, but possibly residents of surgical sub-specialties should have more training with specific endoscopic procedures. I insist that I am not talking only of colorectal surgeons but of all the sub-specialties that require endoscopic procedures. That is why I also believe that we should avoid considering the economic aspect as a variable when performing an endoscopy; I think that would be a serious mistake. Endoscopy is a working tool; it cannot be used for economic profit. Like any other tool well used, endoscopy may become an additional resource of money, but this cannot be the reason why surgeons perform endoscopies.

I would like to comment on the paper. Clearly, one of the most important aspects of this work is the possibility that when the surgeon performs the endoscopy, he/she can resolve the complications more easily and quickly, which I believe is the reason why the consequences of the complications have not been so significant. The study does not reveal if there is any difference between endoscopies performed in inland cities and those performed in the capital of the country, not only in terms of complications, which obviously have not been different, but also in terms of the quality in endoscopy currently measured using a number of indicators as cecal intubation rates, withdrawal times, quality of the report, number and type of polyps detected, and other indicators that would be interesting to discuss and compare on another occasion. I believe that this has to do with the conclusions, we can only conclude with this study that surgeons trained in surgical subspecialty residency programs can perform the procedure. My congratulations again to Dr. Amarillo for bringing this important topic to the Academy.

Hugo A. Amarillo: We thank Dr. Rotholtz for each of his concepts, we agree with the first part, and we are grateful that he has strengthened each of these concepts.

We also agree with the idea of quality of endoscopy, but unfortunately, due to the study design, we did include it because it would have turned out to be an extremely complex and perhaps much more difficult task to carry out in our field. For this reason, we focused on safety and training, and I also agree that when each surgeon follows-up his/her patients and their complications the diagnoses may be made earlier and this obviously has an impact on the patient›s outcome.

This study or this experience does not begin in 2011 when data were collected, but is the second part of a previous retrospective registry that we have already published in the journal of Sociedad Argentina de Coloproctología and where we had also found similar results with the same work group, so I think this encourages all surgeons, particularly colorectal surgeons, but as you said, surgeons from any area of surgery to perform colonoscopies as part of their routine practice. I believe that the economic factor is also a possibility of working in this field, and this can be observed in the United States when there are studies that differentiate between doctors working in rural areas and those who live in large cities, where they have to perform basic endoscopic procedures, and I believe that this is the point we wanted to highlight.

Oscar C. Curto: I congratulate the authors for the paper presented, it is very interesting, but there is a hidden contradiction between what you intend to say, to encourage residents to continue their training by attending a gastroenterology service to do both lower and upper digestive endoscopies. I do not see residents here, at least, there may be one or two. But apart from the fact that general surgeons specialized in colorectal surgery can perform surgery, the ideal situation is that residents can rotate through gastroenterology to learn how to perform endoscopies in the same way they rotate through the intensive care unit. I am happy to hear Dr. Leiro speaking of the situation in the Hospital Pena but that does not happen in all the services due to the lack of communication between the heads of surgery about the papers that are presented in the Academy because otherwise this session would be attended 50% of the residents if the aim of the study is to encourage residents to complete their training program in general surgery with this practice. My congratulations again to all of you.

Hugo A. Amarillo: Thank you Dr. Curto. Your comments give us the opportunity to clarify this issue. This study is aimed at residents, surgeons, heads of department and all those who want to take some of these concepts and I repeat the concept of the official story of flexible endoscopy, only 4% of training in endoscopy, in rotations in endoscopy is in charge of surgeons, most trainers are gastroenterologists and this does not result in benefits for the surgeon. Only between 7 and 27% of residents complete that rotation, we cannot estimate or measure it objectively. That is why I think it is important to produce curricular changes, as Dr. Santas said; we must start from the beginning of their training and insist that although at this moment perhaps rotation may be a solution, in the future that rotation must be performed within the same residency in general surgery.

Juan C. Patrón Uriburu: I would firstly like to congratulate Dr Amarillo and those who participated with their opinions. You managed to carry out a collaborative work in our environment, which is something extremely difficult, hardly anyone wants to share their cases so well done, and I wanted to ask you a couple of questions. It has already been demonstrated that surgeons are able to perform endoscopies; this has already been published in small and large studies. So, as you are quite involved in endoscopy, I want to know, how do you think we should manage this with our colleagues, the gastroenterologists? Should we perform different procedures or the same kind of procedures? Should we move forward towards the novel colonoscopy procedures, the submucosal dissections? Do you think they should be performed by surgeons trained in the technique or by gastroenterologists? I would like to know your opinion about how us surgeons should focus on endoscopies knowing that we can perform them and where we are going.

Hugo A. Amarillo: Thank you Dr. Patrón Uriburu for your comments. I will divide the answer into two parts because in the first part, although obviously there are many publication on surgeons› ability to perform endoscopy in the international literature, it is still not clear how these surgeons should be trained, and that was our target. The only thing that we can demonstrate from this study is that residents in a surgical subspecialty program were adequately trained and could repeat it with the same results, so I believe that tool should be presented to the authorities for the accreditation of the residency program. And please excuse me for the second part, because it is an absolutely personal opinion and unfortunately based only on one opinion. I believe that the best solution is to perform colonoscopy or flexible endoscopy together with gastroenterologists, because the only thing that should matter to doctors is who will benefit from this procedure, and certainly in the case of a very difficult polyp or an endoscopic mucosal incision, the clinician and the surgeon should be present in case of perforation, so that they can solve not only the difficult resection, but also the complication.

Jorge L. Manrique: About 40 years ago, digestive endoscopy was shared with gastroenterologists, but it was not an exclusive hunting ground for gastroenterologists. For some unknown reasons, surgeons abandoned the practice particularly after the development of flexible endoscope Colonoscopies started with gastroenterologists, not with surgeons, and 30 years ago surgeons were not interested in this area which remained in the hands of the gastroenterologists who even proposed that they should perform therapeutic biliary laparoscopy because they were really better trained in endoscopies and laparoscopy. At the beginning, gastroenterologists were better trained in laparoscopy than surgeons who felt disregard about making a diagnosis through a tube, which was true in the 80s; then things changed. Formally I believe that public institutions should have their own endoscopes to train residents to perform endoscopy; thus, curricular changes would be essential because gastroenterologists are not very willing to share the hunting ground. In the same way that pediatric surgeons do not let rotations of general surgeons because it is a private hunting ground, then if we want to recover that I think the curricular change is valuable for the patient who will be better treated by one person and not by a team of strangers even on a multidisciplinary basis; the fact that the face is the same and the commitment is the same and one person has the control is far superior to a collegiate control with worse outcomes and the results are consistent with those of patients well followed-up. The number of cases you present is very important because it is a fact, with 25,000 cases you cannot say that it is an opinion; this is true, but I remember that 30 years ago we presented perforations with 5,000 rigid endoscopies and 200 flexible endoscopies at the congress of surgery and the work was rejected because it could generate risk of legal claims. On the other hand, we know the incidence of perforations which can occur with any endoscopist and this is a possibility of the complications of endoscopy and one has to accept this fact. No one would deny today that you can perforate a colon during a colonoscopy although it is not very common according to your excellent presentation, so I think your study has too many positive aspects that deserve my congratulations.

Hugo A. Amarillo: Thank you Dr. Manrique for the comments and would only like to add that perhaps we should pay attention to gastroenterology residency programs. Gastroenterology residents spend nearly 80% of their time in an endoscopy unit and surgeons do not.

Oscar C. Andriani: Well I join in the congratulations to Dr. Hugo Amarillo and the co-authors for this presentation and I think that the previous discussions allow me to talk about the current management of complex diseases despite I am not a coloproctologist. The subspecialty is more complex, learning is more complex too and here I would like to emphasize the importance of transversal specialization, that is, this does not need to be a competition between gastroenterologists or surgeons, but they should rather work in cooperation in a multidisciplinary unit, in a unit of coloproctology. In this way, I believe that gastroenterologists and colorectal surgeons can work together as in the case of the esophagus as Dr. Amarillo has emphasized, but I wanted to highlight the importance of multidisciplinary and not competitive work. Thank you very much.

Hugo A. Amarillo: Thank you Dr. Andriani, I agree with all your comments.

Alfredo P. Fernández Marty: I want to talk about the managerial aspect as I agree with the academic, medical and educational aspect. As many co-authors are from Salta, I remember that a very good surgeon who worked in the city of Salta was banned by the medical association from performing endoscopies and if he did so, his practice was secret. I do not know if Dr. Amarillo or any colleagues from Salta can reply if this situation has reverted. Because there is also a managerial aspect to consider. I come from a hospital that has an endoscopy service and a diagnostic imaging service; it is not easy to fight against endoscopists or against specialists in diagnostic imaging to incorporate these capabilities outside the operating room; maybe these capabilities can be incorporated in the operating room. So as there are many surgeons from the provinces, my question is if this managerial aspect has been solved in the inland country and here in the capital city. Probably private hospitals have solved this aspect, but what about public hospitals? In public hospitals it is very difficult to obtain the necessary equipment, to have one›s own endoscope in the operating room.

Hugo A. Amarillo: Thank you, Dr. Fernandez Marti, for opening the discussion to the managerial aspect because it is really a problem that unfortunately has not been solved in the provinces. In Jujuy, Mendoza and many other inland cities, surgeons still cannot bill for endoscopy procedures, I do not know if they can perform endoscopies, but they cannot bill. In Tucumán in 1979 the deceased Dr. Amarillo performed the first colonoscopy in a public hospital and it was perhaps his vision in Tucumán that allowed the different instances to allow and facilitate surgeons to bill and perform colonoscopies and perhaps we must visualize this example when we have already lost ground and we have to start again. The concern with this type of experience is precisely for that reason, because surgeons are fully trained and capable of doing so and we have to move towards the issue of being able to perform it in the management field.

Enrique A. Sívori: I would like to make a comment about what has happened to us in esophageal surgery and relate it to what happens in colorectal surgery. There has evidently been an invasion of treatment of achalasia, of esophageal diverticula by gastroenterologists who already treat significant diseases directly through endoscopy; this has led to surgeons to start doing the same. In the case of the colon, which is what is being discussed today, it seems to me that diagnostic colonoscopies prevail over the resection of large or small polyps. So the question is, are there studies with a significant number of patients comparing colonoscopies performed by gastroentorologists versus those performed by surgeons in relation to mortality and complications? Is the incidence of complications greater? Are there any studies focused on these questions? Because it is not mentioned in the work and I consider it important as surgeons have always insisted on a direct relationship between the volume of patients treated and the results, so if the results between diagnostic colonoscopies performed by surgeons are the same or comparable to those performed by gastroenterologists, I think the method should be carried out. I repeat, in the case of the esophagus gastroentorologists are invading therapeutic procedures for important diseases, so surgeons must deal with this area of the digestive tract because otherwise they will lose an important number of patients; that is what I wanted to ask and what I wanted to comment on. Thank you very much.

Hugo A. Amarillo: Thank you, Dr. Sívori. In fact, something similar happens with the colon. Although flat polyps are not the most common lesions, they are at risk of complications during a therapeutic maneuver. A similar situation occurs in the rectum, where those who can attend gastroenterology congresses listen to those who train endoscopists to practice in the rectum because an endoscopic resection can be safely performed in the rectum. And when one compares the results of gastroenterologists and surgeons, although it was not our intention, one sees that the results are similar and for example Dr. Marchello cannot perform it in his area because he is also attacked by gastroenterologists, but he has seen that surgeons have a tendency to resect more difficult lesions, larger polyps and perhaps lesions that gastroenterologists would not agree to do but the results tend to be similar.

Carlos A. Apestegui: Firstly, I congratulate you for bringing this work to the Academy and provoking such an interesting discussion. I simply want to make an extra contribution to what Dr. Manrique said. It is very difficult in Argentina to think 20 or 25 years ahead, but in this same Academy, in this same place, and sitting a slightly further to the left, doctor Benati said 25 years ago that rigid or flexible endoscopy should be done by surgeons because it was crucial for the proper subsequent treatment, and he called on the members of the Academy, especially the heads of department. Obviously, the call of this great master was not heeded because otherwise this discussion would be taking place today. So, it is appropriate to insist now on what I thought was essential 25 years ago, but for a personal matter I learned it with Dr. Piero, so I congratulate you, Dr. Amarillo.

Hugo A. Amarillo: Thank you, Dr. Apestegui, only one comment in this regard that is also linked to the previous question and has to do with the lack of publications in the national literature and how the results vary not in terms of complications but in terms of the findings reported by gastroenterologists versus those reported by the attending physicians. We have all experienced that the tumor reported to be located at 50 centimeters was not at 50 centimeters and it would be very interesting to make a subsequent evaluation.

Juan Pekolj: I congratulate Dr. Amarillo and Dr. Salomón for the presentation. I think this is a very important topic to present in this society and in associations. Five years ago, Asociación Argentina de Cirugía started developing the idea of recovering endoscopy and I think that speaking in this way today means that what began 5 years ago or 25 years ago is bearing fruit and scientific institutions should be involved in the subject. Asociación Argentina de Cirugía has created a sub-commission of endoscopy with representation of surgeons nationwide, including surgeons of the lower and upper digestive tracts, who, besides teaching and conducting workshops all over the country, are also involved in the political struggle. So last year, as president of the Academy and with members of Asociación Argentina de Cirugía, the Mini Invasive Surgery Committee and the Sub-Committee led by Dr. Sequeira, we went to the Ministry of Health to start working with gastroenterologists and endoscopists, and the concept that endoscopy is not a specialty but a tool that we are outlining today emerged there. The concept of expertise rather than specialty emerged. So, we have an expert in lower digestive tract, biliary tract, in head and neck, who need to learn how to perform endoscopies as part of the skills they must develop. I believe that this concept is very important due to how it is positioned, and neither Tucumán nor Salta can tell us that we cannot perform of bill for endoscopies because the concept is the same. The Ministry is so involved that another meeting will be held in the Senate tomorrow to discuss this issue; this is politics and it will be difficult as long as the government and institutions do not regulate it. I believe that we have to get involved so that each of us in our work place can show what we are doing, our standards in terms of safety and quality, as they can say we do not perforate the colon but they achieve cecum intubation in 30% of the cases so we have to look for both things: quality and safety, which has been demonstrated here. The residency program must be the setting for introducing this concept, but we cannot expect residents to finish their training with expertise in endoscopy, because they will have to perform a significant number of procedures, and I believe that the introduction is the way, and they will probably acquire the expertise in the subspecialty they decide to follow. I believe that we must be very careful when we train surgeons in endoscopy because the worst thing that can happen to us is to have bad results and loose everything we have gained. Undoubtedly, endoscopies should be part of fellowships in subspecialties, so those receiving training in esophagus must know how to perform endoscopy and obtain the accreditation to perform upper endoscopy and colonoscopy as well. What have we done in our hospital? Firstly, we do not argue. In our hospital, colonoscopies are performed by gastroenterologists and colorectal surgeons; approximately 20% of the colonoscopies performed in the Hospital Italiano are done by surgeons; so, there is an important workload to deal with. At this moment, we have one staff surgeon trained in upper digestive tract for the first time, and he is going to start working. So basically, my question is that we are talking about diagnosis and therapy, and we are forgetting intraoperative endoscopy. Intraoperative endoscopy must be the tool used by surgeons because the surgeon is the king in the operating room, so we need to perform intraoperative endoscopy to manage intraoperative complications. Obviously, we must be trained, but I believe that this is an unexploited area that can be applied in the upper and lower digestive tract. It is not acceptable for us to perform a colon resection without the tumor in the specimen and this has happened, and the tumor had been tattooed, so, we must know how to use it intraoperatively. The question I want to ask is: How do you perceive the implementation of intraoperative endoscopy? You talked a lot about complications. Are you worried about complications such as perforation? and I am talking about something that happened to us in the hospital. Are you performing endoscopy with air or with carbon dioxide? Because I believe that this makes a total difference in our management of complications. My congratulations again to all of you for the topic and the presentation.

Hugo A. Amarillo: Thank you very much Dr. Pekjol for all the comments, we are well aware of the work that the Asociación Argentina de Cirugía is carrying out and that is what will allow us surgeons to advance on all the topics that we have previously discussed. With respect to the specifics of the questions, we are in complete agreement that an intraoperative colonoscopy should be performed by a surgeon and that is precisely why perhaps residents need to be trained in basic endoscopy because perhaps while the surgeon is operating, the resident can check an anastomosis or a of a mega-colon to go on with the resection or control an intraoperative bleeding from a low anastomosis or find the lesion that had not been tattooed, so in that sense, I think, we have to go on with intraoperative endoscopy and that is the reason to be trained. We use carbon dioxide in the Hospital Británico and air in the provinces, except in Cordoba, and we are moving toward new carbon dioxide equipment devices, but obviously that makes a complete difference in case of therapeutic endoscopy.

Manuel R. Montesinos: A specific question about the few cases of patients with complications: I want to know if they were specially analyzed by age or associated comorbidities, to see if they are more likely to present complications to be aware that complications and endoscopy are more dangerous in this sub-group of patients, Thank you.

Hugo A. Amarillo: Thank you for the question. Indeed, as Dr. Montesinos says, when we made the analysis of all the characteristics, gender, age, and history of polypectomy coincide with the literature, so we have not found a different risk group.

Marcelo F. Figari: I would like to ask Dr. Amarillo a question about education. I was surprised that simulation was not commented in the presentation or by any of the colleagues who expressed their opinions. And there is a wide range of courses in medical education using simple simulators to acquire skills for three-dimensional manipulation in a cavity or more complex simulators to simulate polypectomies, even with haptic capabilities. in which stage are we? Because it seems to me that it would be not only a step to take for patient safety, but for increasing training opportunities outside the real scenario.

Hugo A. Amarillo: Thank you Dr. Figari, your comment is excellent. Basically, we did not focus on that target when we developed the work, but nowadays training is very different from what it used to be 20 years ago, when I was trained in colonoscopy. There were no such simulators available in Argentina, particularly in Buenos Aires. Nowadays I think that you obviously have to use a simulator before practicing with a patient, and that before setting up a whole educational stage in simulation we have to focus on which attitudes or skills should residents acquire, because if they will have to spend hours of practice in simulation and then they will only perform rectoscopies, we are losing resources. So, I believe it important to define the curricula, to know what to do in each instance.

Jorge A. Latif: Thank you very much, Mr. President. I cannot avoid congratulating you on the work you have brought us tonight. Looking at the results, it is obvious that your conclusion is that it is feasible and safe. My impression is that considering that the participating centers as Hospital Británico, the center and your center are highly specialized in the matter, I agree with the results, with the low results in complications that you have had and surely when you compared with the second part, training in those same centers is responsible for those results. With regard to implementation in the curricula, I believe that all of us in this room tonight, and despite some of us do not manage the surgery departments, we all agree that we have to do this and that our residents have to take their first steps in training in endoscopy during the residency program. Four years ago, we were lucky to work with Dr. Sequeira, still at that time, and we implemented surgery, endoscopy in general surgery and coloproctology, that is, at this moment in Clínica Modelo de Lanús all the staff physicians perform upper and lower gastrointestinal endoscopy. Since this year, we have implemented the mandatory training for residents in surgery during their 4-year-education program in the curricula of Colegio Médico de la Provincia de Buenos Aires, Distrito II, and over the last 2 years we have intensified this. Some laboratories have offered more simulators for complex endoscopies and different options for the endoscopist to us and to other people, and they will have to take the course of the Asociación Argentina de Cirugía de Endoscopía which I think is also important and that will provide a curricular background to be able to work. The Sociedad Argentina de Coloproctología is also working on that in the two residency programs accredited and with the fellows in our training programs in laparoscopy and digestive endoscopy in each of the departments of surgery. And finally, I do not agree much with Dr. Rotholz that we do not have to be paid for these procedures. Nowadays payment for these procedures as a diagnostic or therapeutic tool is not formalized at all in the province of Buenos Aires. For example, we can bill many prepaid medical systems or workers› health insurance systems for lower digestive endoscopies as qualified specialists in coloproctology, but we cannot bill for upper digestive endoscopies, and the situation is even worse in the provinces, where surgeons deal with many issues. The truth is that, going back to residents› education and training, nowadays residents should finish their training program with the same skills in digestive endoscopy they have in ultrasound in trauma setting, and in some centers with better training in diagnostic imaging, and I believe, as Dr. Leiro said, that bringing this subject into discussion in this setting is of utmost importance. Congratulations.

Hugo A. Amarillo: Thank you, Dr. Latif, for your comments. And just a small contribution about the residents; the residency program and training has been shifting thanks to technology, residents› attitude towards new techniques and new technology has also been shifting and they have much more ability, they are the offspring of technology, they were born with the innate knowledge of technology, they are more capable of learning technology than when we were trained and their demands to be trained are higher. When I was a trainee, my first rotation in endoscopy was during my third year of training, and today first-year residents can perform basic endoscopic maneuvers, and it is much more likely that they will be able to solve the problem better than we could, so it is clear that we have a raw material that must be worked on, because, as I said, it is no longer a matter of dispute and is part of a surgeons arsenal.

Mario C. Salomón: Thank you very much to Dr. Amarillo for giving me the opportunity to present his work and to all the members of the Academy for the contributions you have made. I would like to clarify some aspects of costs. When I said I so, I really thought perhaps the Academy is not the place to talk about costs, but I think that we have to stop being hypocrites and try to do as American physicians who receive education in economy in the School of Medicine, and the economic aspects should also be dealt with in the academic field. Furthermore, the first thing I said was to improve the clinical aspect, delivery of care, and undoubtedly, if we perform an endoscopy on a patient and operate him/her, we will provide much better follow-up and treatment, which is not only based on the economic benefit obtained by performing a colonoscopy. The intention of Dr. Amarillo and our intention in presenting this work in the Academy is not only focused on residents, something similar happened with laparoscopy. The Academy is the setting where the heads of departments and prestigious and influential people gather. We can only encourage residents to learn. Residents from the Hospital de Gastroenterología make their rotation through endoscopy in our hospital. In our hospital, residents in general surgery rotate through gastroenterology to learn upper digestive endoscopy, they come with us to do colonoscopies, so this struggle is up to us, and no matter how much is said about not being against the gastroenterologists, it is a struggle and every day we have to confront gastroenterologists who want us to stop performing colonoscopies. We have the same right to perform colonoscopies as we have the right to perform upper digestive endoscopies because we are authorized to perform them and the surgeon who can perform a colonoscopy can also perform an upper digestive endoscopy without any problem. I think the intention was to encourage everyone, starting with the resident, the medical student and the members of the Academy, it is the responsibility of each head of department to make their residents in general surgery or in coloproctology perform the endoscopies and I have no doubt that this will happen through the years without problem as the Asociación Argentina de Cirugía and Sociedad Argentina de Coloproctología have been doing so. Dr. Pejkol spoke of 20%, we perform almost the same number of colonoscopies with the gastroenterology service. In patients referred for colonoscopy, gastroenterologists come to or operating room, they perform the upper digestive endoscopy and we perform the colonoscopy. We really try to keep a good relationship, yet some difference may arise. There are managerial issues. When we hold meetings with residents trained in our department or in others and who moved to the inland of the country, they claim they cannot bill for the endoscopies and that depends on all the achievements made by Asociación de Cirugía, la Asociación de Coloproctología or good contacts to reach the Ministry. In some way, those trained in colonoscopy or upper digestive endoscopy during the residency are very well trained to perform endoscopies and any type of procedures. Another item discussed was the occurrence of complications, as bleeding after an anastomosis; we ask for the endoscope, we perform the colonoscopy and we solve the problem with a clip or electrocoagulation and without depending on the gastroenterologist who comes at the time he/she wants or is not willing to perform an endoscopy, a colonoscopy in a patient who is bleeding, So, there are many advantages, the intraoperative control of anastomoses is another item, so undoubtedly, digestive surgeons, colorectal surgeon and chest surgeons have to perform endoscopies. These methods are not exclusive of a group, so again there have been surely many items that deserve discussion. Thank you very much for all the contributions.