Endoscopy: Not Just For Specialists

With new equipment made readily available, endoscopy can be used by regular vets.

Endoscopy, commonly used for biopsies, gastropexies and laparoscopic ovariohysterectomies, is becoming more popular with veterinarians for more complex procedures.

As the use of non-invasive methods increases, many veterinarians are learning to use endoscopic equipment. While a veterinarian investing in endoscopy equipment might not perform all possible procedures, he or she can offer many cutting-edge treatments.

“There are many benefits to performing endoscopic surgery,” says Athens, Ga., surgical consultant Clarence Rawlings, DVM, MS, Ph.D., Dipl. ACVS. “The patient experiences less stress, less pain and can return to normal performance levels faster. Clients often have an aversion to major surgery but are often more comfortable with a less invasive procedure. As veterinarians, we feel like we’re doing a better job when using it for the right procedures.”

Dr. Rawlings says new equipment is always exciting to use, but he warns against using endoscopic equipment for the wrong reasons. Other options may be available, he says, and sometimes a case may need to be referred.

“I’m always asking myself if I should perform another physical exam, more blood work or perform an ultrasound,” Rawlings says. “Make sure you’ve run through those things first and, of course, have client approval.”

Training Comes First

First and foremost, get trained on the equipment before buying it, endoscopists say.

“The most difficult obstacles to successful endoscopy are achieving proficiency with hand-eye coordination and learning to integrate endoscopic equipment performance with basic patient anatomy to achieve the most efficient and successful procedural outcomes,” says Jacqueline Whittemore, DVM, PhD., Dipl. ACVIM (SAIM), an assistant professor of medicine at the University of Tennessee, Knoxville.

“The time frame for proficiency depends on a number of things, including quality of training, access to a mentor, ability to visualize and integrate equipment and patient anatomy, the procedure to be mastered and even video game experience. Beginning endoscopists should remind themselves frequently that endoscopy is a skill, not a talent.”

Veterinarians should get a feel for the difficulty of the procedures they want to perform, specialists say.

“Many of the common procedures are relatively easy to learn, and I can train most general practitioners to perform them in a two-day course,” says Timothy McCarthy, DVM, PhD., Dipl. ACVS, of Cascade Veterinary Referral Center in Tigard, Ore. “I have found that cystoscopy, rhinoscopy and otoscopy can be learned by most veterinarians in this time frame. I have also trained veterinarians to perform lap spays in a two-day course where each participant gets to do at least three procedures.

“They’re not experts at this point but have the skills they need to perform cases safely.”

Why do some veterinarians balk at performing certain endoscopic procedures? Rawlings says the No. 1 reason isn’t the equipment cost.

“Using endoscopy is more about comfort level than anything else,” Rawlings says. “Some veterinarians are content with doing what they’re doing.”

Of course, price is a factor and needs to be considered.

“Endoscopy requires a relatively huge upfront cost, and there is a very steep learning curve for the veterinarian and practice technicians,” Dr. Whittemore says. “The payoff is enormous, but it can only be so if there is a strong belief in the benefits of endoscopy and a strong commitment to developing the necessary skill sets.”

MaryAnn Radlinsky, DVM, MS, Dipl. ACVS, an associate professor at the University of Georgia College of Veterinary Medicine, says every veterinarian should be able to move from an endoscopic procedure to a traditional method on a moment’s notice.
“If you’re not comfortable doing an open procedure, you shouldn’t do it endoscopically,” says Dr. Radlinsky, past president of the Veterinary Endoscopy Society. “If something goes wrong, the veterinarian needs to be ready and able to finish the procedure without the endoscopy equipment.”

Equipment Maintenance

Veterinarians considering such a purchase may wonder what happens if the equipment breaks. What is the cost of replacing or repairing the item? Will it be covered under warranty? How many days will the practice be without endoscopy while repairs or replacements take place?

“Name it and it can go wrong or break,” Dr. McCarthy says. “The most common failure of equipment is leakage of flexible endoscopes. Other common problems are bending or breaking the smaller rigid telescopes and breaking fibers in flexible endoscopes. When they are properly used and cared for, endoscopes, both rigid and flexible, will last a lifetime. The full quality range of endoscopic equipment is available in the veterinary marketplace. The big name manufacturers all make good equipment.”

Endoscopy veterans warn against making an eBay or private seller purchase, noting that a warranty likely will not be included and that the quality cannot be guaranteed. Furthermore, education, maintenance and troubleshooting options found with manufacturers may be absent.

Reserved for Specialists

Endoscopy is becoming the standard of care for thoracic surgery, especially for a pericardectomy, Radlinsky says.

“Different medical conditions can cause fluid to build in the pericardial sac and cause pericardial effusion, such as cancer of the pericardium,” she says.

“Sometimes, more techniques are performed to correct a chylothorax or to repair a congenital deformity. These types of procedures—endoscopic or otherwise–would likely always be performed by a specialist. Primary care practitioners may choose to refer to a surgeon who performs endoscopy, especially for these procedures, because of the complexity.

“I like the outcome after endoscopic surgery,” she adds. “There definitely seems to be a more rapid recovery, especially when you consider the amount of surgery that can be done internally through very small incisions.”

Scoping of joints is a procedure experts recommend be done by a board-certified specialist or by a practitioner with a lot of experience in joint care.

“Arthroscopy is the most difficult technique that most surgeons will learn in their careers,” McCarthy says. “It takes more than one course plus onsite coaching for most surgeons to become proficient in this technique.  I travel to practices, and we perform arthroscopy procedures on patients until the doctors are proficient and don’t need me anymore.”

Senior animals in particular may benefit from endoscopy considering their decreased ability to heal compared to younger animals and their heightened anesthesia risk. Because endoscopy can minimize the need for additional anesthetic, it might be a safer option.

A Boon for Seniors

“Endoscopy is a tremendous tool for senior animals,” Rawlings says. “If an animal has an abdominal mass, endoscopy can be used to take a biopsy. An evaluation and decision can be made about the animal’s treatment with minimal disturbance.”

Veterinarians who do not own endoscopic equipment should consider referring certain cases to a colleague who does.“Many endoscopic procedures allow us to do a far better job with less trauma and pain for the patient,” McCarthy says. “Clients need to be offered this choice. Some clients will not or cannot spend the money for minimally invasive procedures performed by a specialist, but they should be given the opportunity.

“I have been saying for years that endoscopy is a quantum leap forward in our diagnostic capabilities. More recently I have added therapeutic capabilities to this statement.”

Despite the benefits, experts still say endoscopy isn’t always a replacement for traditional surgical procedures.

“Endoscopy is not and cannot always provide a better level of care than traditional surgery,” Whittemore says. “As has been found with ultrasound versus radiology, endoscopy has neither the same limitations nor the same benefits as surgery. There are situations where surgery still offers a better outcome than endoscopy, even in human medicine.

“Minimally invasive procedures will continue to displace traditional surgeries, but very complicated and also simple situations will likely be best handled using traditional surgical methods.”

McCarthy says he has a two-page list of endoscopy procedures he performs and believes all of them have the potential to make more traditional surgical methods obsolete.

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