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Introduction

George Gershman and Mike Thomson

In the late 1960s, flexible gastrointestinal endoscopy emerged as a novel diagnostic tool but was not employed routinely in children until the mid‐1970s when pediatric flexible esophagogastroduodenoscopes became commercially available. In the decade that followed, there was a significant expansion and application of this modality in children. As the result, many discoveries and improvements in diagnosis and treatment of various pediatric GI disorders have been made despite the limitations associated with light and image transmission through the fiberoptic cables – the technology which only allowed the operator to look down the scope through the eyepiece.

The advent of the microchip with a video camera sited at the tip of the endoscope has advanced the optical imagery significantly. The days of an operator’s watery eye “glued” to the endoscope head and poor‐quality images due to fiber breakage within the optic cables and condensation of water under the lenses at the tip of the instrument are long gone. The only “advantage” of fiberscopes was that no one else knew what you were looking at and there was a propensity for claims such as ‘Oh yes, I got to the terminal ileum’! Nowadays, everyone can see where you are in the GI tract on the screens so there is no hiding …

Modern endoscopes include high‐definition images, high magnification, confocal endomicroscopy with up to 1000× magnification, narrow‐band imaging with focus on various light spectra to allow identification of dysplasia and polyp pit pattern, autofluorescence and other diagnostic modalities. Furthermore, the therapeutic capabilities of the modern endoscope are phenomenal and include up to 3.8 mm working channels and even scopes with two working channels to allow more sophisticated work. Very narrow (4.5 mm) scopes are now available to allow endoscopy in the smallest of infants/neonates and these are now applicable in older children for outpatient transnasal endoscopy without sedation. Three‐dimensional imaging techniques are standard in most colonoscopes which enables identification of loops during ileocolonoscopy, speeding up the process and making it safer and less uncomfortable when it is done without general anesthesia. These concepts are now aided by the use of insufflation using carbon dioxide which is much more quickly absorbed than air.

In addition, endoscopic accessories have developed miraculously and allow many therapeutic procedures to occur which had previously been the domain of surgical options only. These include endoscopic fundoplication, per‐oral endoscopic myotomy for achalasia, percutaneous jejunostomy, duodenal stenosis treatment, fundal variceal ablation, pancreatic pseudocyst drainage and many others discussed in the corresponding chapters of the book.

In parallel with the advances in equipment, we have seen an enormous upskilling of the operators mainly due to the focus on training – this has been made possible by the greater availability of virtual models, hands‐on animal training and more investment in one‐to‐one fellowships and short focused therapeutic endoscopic courses over the last 10–20 years. Online portfolios and direct observer procedure skill assessments are the cornerstones of these advances. Virtually every large GI meeting now has a hands‐on endoscopy component and often a live endoscopy segment as well.

Virtually every year, a new endoscopic application is developed and many of the recent advances are included in this textbook – such as the over‐the‐scope clip for perforation closure, Hemospray® for diffuse GI bleeding, Stretta radioablation of the distal esophagus for reflux treatment, and then the concept of natural orifice transendoluminal surgery (NOTES) needs a mention as the newest kid on the block. This latter exciting technology is in some ways a modality looking for an appropriate application, especially in children, and is discussed at the end of the book.

We have tried to make this text the definitive one for pediatric endoscopy and we hope you enjoy reading it. No doubt more advances in technology will have been developed by the time this book hits the shelves but this is to be applauded. If the velocity of advances continues at the present pace, there is no barrier or horizon that is safe from endoscopy. It is reasonable to say that the gastrointestinal endoscopist should have the aim to make the GI pediatric surgeon virtually redundant. However, it has to be said that increasingly, the two disciplines are working more closely together and pediatric surgeons use endoscopy more and more themselves.

We hope that this book will enthuse the younger generation of trainees to follow the path of minimally invasive solutions to every problem that the GI tract produces in children. We may learn a lot from our adult colleagues but conversely, with our exposure to congenital abnormalities, we may be able to take a lead in these areas also. Imagination is our only barrier.

We would like to thank our colleagues who have kindly given up their valuable time to contribute some really fantastic chapters and images. We hope you really enjoy reading the book and that you gain a lot from it. The images and videos and webpage will allow knowledge to be disseminated widely. Most, if not all, of the world experts in pediatric endoscopy have contributed and we are truly grateful. We would like to thank the publishers, without whose guidance and help this would have been impossible.

This journey would not have been possible without the love and support of our families.

Mike:

thanks to Kay, my wife, and Ella, Jess and Flo, my wondrous daughters who put up with their old dad – especially editing the chapters when on holiday!

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