with foreign body extraction, diathermic loops for polypectomy, sclerotherapy needles and bands (silicon or latex) for variceal eradication, dilation bougies and pneumatic balloons, hemostatic clipping devices and electro‐ and photocoagulation devices for hemorrhagic lesions, and gastrostomy kits. The reliable use of these tools needs constant maintenance by skilled staff and good training to guarantee a safe procedure.
Training
The great progress of the video endoscopic equipment has rendered teaching and training a simpler task through participation of the trainee in the procedure. A growing number of “train the trainer” courses has also been implemented worldwide, with focused programs in Australia, United Kingdom, and Canada. Computerized programs and simulators have been developed and are very useful to familiarize the trainee with the space distribution of organs and to learn to exert the right movements of the endoscope to reach the targeted organ or perform a delicate therapeutic procedure [35–38].
Also, several good “hands‐on” courses with live demonstrations and training on porcine models have been developed in Belgium, France, Italy, the Netherlands, UK and United States. Finally, the trainee should complete their training in a reputed pediatric center, large enough to get the necessary experience and with support from an experienced pediatric gastroenterologist.
Evolution
The improvements that have occurred in instruments, sedation and anesthesia during the last 40 years have transformed pediatric endoscopy and gastroenterology. Pediatric gastroenterologists are now able to perform difficult diagnostic and therapeutic procedures that used to be left to the adult endoscopist, such as endoscopic ultrasonography. These procedures likely need to be concentrated in referral tertiary hospitals that can afford the costly equipment and specialized staff. These highly specialized units can safely count on such facilities as surgical and intensive care assistance, in case of adverse events because one should always bear in mind that endoscopy is an invasive procedure with inevitable risks. The constant progress in instrument quality has considerably enhanced the diagnostic power of endoscopy. Several instrument makers have implemented optical zooms but also more sophisticated methods such as dyeless virtual chromoendoscopy, Olympus Narrow Band Imaging (NBI®), Fujinon Flexible Spectral Imaging Color Enhancement (FICE®) and Pentax™ i‐Scan®.
Mechanical improvements have enhanced the maneuverability of the endoscopes, for instance the adjustable stiffness of colonoscopes that facilitates access to the whole colon, insertion into the ileocecal valve and exploration of the terminal ileum. Exploration of the upper GI tract beyond the proximal jejunum and the terminal ileum is also possible with the double balloon enteroscope [39], which permits not only visualization of small bowel lesions but also biopsies and polypectomy. The most spectacular progress has been the wireless video capsule endoscopy (WCE) which allows exploration of the complete small bowel [40,41] matched with an array of enteroscopes which can traverse the deepest parts of the small intestine to complement findings seen on the WCE.
Conclusion
Endoscopy is undoubtedly an invasive technique and invasiveness is not welcomed in pediatrics. However, there is no doubt that GI endoscopy has a promising future in the field of therapeutic and interventional endoscopy with more improvements to come.
Gastrointestinal endoscopy in children has evolved from a rather confidential tool in the early 1970s, available to very few pediatric gastroenterologists with special skills and curiosity, to a routine diagnostic technique present in almost all pediatric gastroenterology units throughout the world. The stimulating adventure granted to the early “discoverers” has been replaced by less thrilling but probably more useful procedures since continuous improvement of the instruments allows deeper and more audacious therapeutic procedures.
See companion website for videos relating to this chapter topic: www.wiley.com/go/gershman3e
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