In expert hands, these procedures are now being performed with a low frequency of complications and with low recurrence rates. Although current methods are

time-consuming, it seems likely that the procedure will become simpler and faster as platforms are developed that permit simultaneous retraction and cutting. Another potential area is the local treatment of gastrointestinal neoplasms with agents administered via endoscopy, perhaps with guidance from EUS. Potential agents can be engineered viruses that either selectively kill malignant cells or sensitize malignant cells to chemotherapy or radiotherapy. An alternative approach is the application of immunotherapy in pancreatic cancer where an allogeneic, mixed-lymphocyte culture (cytoimplant) is injected into the cancer to initiate a strong tumor-specific immune response. Both approaches have already been used with apparent benefit in preliminary studies.37,38 Despite the above, those who see endoscopic therapy as the future of gastrointestinal surgery should heed the lessons of endoscopic therapy

for gastroesophageal reflux disease. Between approximately 1990 and 2005, various endoscopic techniques were used to narrow the lower esophagus or ‘support’ the lower esophageal sphincter using injectible agents, scarring via radiofrequency energy or the placement of superficial sutures in the gastric cardia. These techniques have largely been abandoned although there are on-going studies designed to replicate

the principles that have been applied in open and laparoscopic fundoplication. For most endoscopy suites, the number of upper gastrointestinal procedures is either static or in decline while the number of colonoscopic procedures continues to increase. The former reflects at least some reduction in endoscopy for upper gastrointestinal bleeding while the latter reflects a focus on colorectal neoplasia, sometimes supported by local and national bowel cancer screening programs. While colonoscopy is likely to be central to surveillance for colorectal cancer for some years, alternative screening options could become available that might decrease Mirabegron the need for colonoscopic procedures. For example, fecal occult blood testing is widely used for community screening but only 1 in 20 positive subjects has cancer at colonoscopy. Conceivably, the detection of DNA mutations or specific cancer-associated proteins in blood or feces could be a more sensitive and specific EX 527 clinical trial indicator of high-risk neoplasms. Other investigations such as CT colonography and MRI colonography might also have an increased role in screening, particularly if sensitivity and specificity can be improved without the preceding use of laxatives.