Colonoscopy and polypectomy is the only way colorectal cancer can be prevented. Colonoscopy with the removal of colorectal polyps began in 1969 at the Department of Surgery, Beth Israel Medical Center, New York, USA. In the early years significant opposition was encountered by some who claimed that these methods were dangerous and unnecessary. Time and evidence based Medicine has proven otherwise. Getting a screening colonoscopy at age 50 is the current standard of care to prevent colorectal cancer.

Dr. Hiromi Shinya (a General Surgeon) and Dr. William Wolff (a Cardiothoracic Surgeon) are responsible for the advancement and development of colonoscopy / polypectomy as we know it today. In the 1960s they established an upper gastrointestinal fiber optic endoscopic laboratory and clinical facility. Their work led to the development of the first flexible instruments for evaluating the entire colon.

Surgeons in the 1960s, Dr. Shinya and Dr. Wolff developed a protocol for a one doctor, instead of two, as the standard for performing colonoscopy. The colonoscope instrument allowed the surgeons to examine all 5 feet (150cm) of the colon/rectum and negotiate all the sharp turns of the intestine. Up until this time the colonoscope was used for diagnostic purposes only.

In 1966 Dr. Wolff, who was the Chairman of the General Surgery department, became interested in a new fiber-optic endoscope that was introduced to the medical field. He teamed up with Dr. Shinya who had just completed his General Surgery residency at Beth Israel, to evaluate if the colonoscope could be used to evaluate the colon and rectum.

In June 1969 they performed one of the first colonoscopies. Three months later, using the electro surgery polypectomy snare designed by Dr. Shinya, they used the procedure to remove polyps. They did not publish their findings until they performed 100 successful procedures.

These surgeons working with the Olympus Optical Company made a further advance which facilitated prevention of colorectal cancer. Dr. Shinya in 1969 designed a wire loop snare to remove a colorectal polyp as soon as it was found. This was a ground breaking advance in colorectal cancer prevention.

Dr. Wolff and Dr. Shinya first described their surgical procedure in The New England Journal of Medicine. This article became known as one of the 20th century’s landmark articles in the field. (Wolff WI, Shinya H. Polypectomy via the fiber optic colonoscope: removal of neoplasms beyond the reach of the sigmoidoscope. N Engl J Med 1973; 288:329).

Colonoscopy expanded and became more widely accepted in the 1970s and 1980s. At first gastroenterologists were averse to performing a “surgical” procedure. With time both the gastroenterologists and the general surgeons were performing colonoscopy on a routine basis. This procedure became especially common among colorectal surgeons as well. In 1983, the Welch Allyn Corporation introduced the video endoscope, enabling the view of an image on a video screen. This was opposed to the technique of only the endoscopist viewing the anatomy, via a small eye piece on the scope.

The colonoscope prompted a radical shift in medical thinking. At the time the significance of polyps causing colorectal cancer was not appreciated. Today the concept of the adenoma to carcinoma progression of polyps to cancer is accepted as fact.

Dr. Hiromi Shinya was born in Japan in 1935. In 1960 he completed his medical studies in Tokyo. Following his internship, Shinya began his residency at Toho University Hospital, with the hope of becoming a neurosurgeon. However, a position was offered to him in 1963 in the USA. He left Japan for New York to complete a surgical residency at Beth Israel Medical Center. In 1967, Shinya became involved with colonoscopy as a senior resident at Beth Israel. Based on his unique experience in abilities while in USA, he received a special visa waiver by order of the President of the USA, to remain in the country to continue his work. His colonoscopy experience as of recent exceeds 370,000 patients.

All Colorectal Surgeons trained in the USA are skilled in performing colonoscopy and polypectomy. Certain General Surgery programs have the volume to also certify their General Surgery graduates to perform EGD and colonoscopy on a regular basis.

On a personal note, prior to making Aliyah to Israel in 2013 I was performing both EGD (gastroscopy) and colonoscopy as a Colorectal Surgeon at Atlanta Medical Center. Based on my study reviewing the colonoscopy abilities of our surgical residents, we presented a poster at the American College of Surgeons meeting. (Redden M, Choat D, Pelta A. General Surgery Residents are able to achieve competency in performing colonoscopy under the guidance of a Colon and Rectal Surgeon. American College of Surgeons Clinical Congress, Washington DC. October 2013. Scientific Poster Presentation). Our surgical residents demonstrated the ability to safely complete colonoscopy and polypectomy more than 90% of the time. No complications were encountered. The current standard in the USA is that General Surgeons, Colorectal Surgeons and Gastroenterologists all perform colonoscopy and EGD. The major difference is that with a surgeon no further consultation is required based on endoscopic findings. If there is a cancer or polyp that cannot be safely removed, or there is a complication, the surgeon takes care of it.

I was surprised to learn, that here in Israel, surgeons do not perform the technique invented and perfected by general surgeons (colonoscopy). For some reason only gastroenterologists perform colonoscopy in Israel. Hopefully, one day in the future this will change. Currently, there is a long wait for colonoscopy due to the limited supply of skilled doctors combined with the higher demand, based on the population needs.

There have been multiple attempts in the literature to replaced polypectomy with less invasive tests to prevent colorectal cancer. However, nothing other than removing a polyp can prevent cancer at this time. With more skilled doctors/surgeons allowed to perform colonoscopy this can improve colorectal cancer prevention. In this manner the Israeli public can only benefit.

In September 2011 Dr. Wolff died at the age of 94. Dr. Shinya is still a practicing surgeon in New York at age 80. Ironically, neither Dr. Wolff nor Dr. Shinya would be able to practice colonoscopy if they in Israel.

 

Arie Pelta, MD (Colorectal Surgeon) can be contacted at ariepelta@gmail.com.